Download - Review 2 Final Sp2011 PDF
-
7/30/2019 Review 2 Final Sp2011 PDF
1/60
The Birth of Community Mental Health(contd)
Community Mental Health Centers Actpassed by Congress in 1963
Expanded community care for theprevention of serious mental illness with
early intervention and outpatient therapy Provided for reimbursement of mental health
services through Medicare and Medicaid
Resulted in the deinstitutionalization of the
mentally ill State mental hospitals were closed
Individuals diagnosed with a mental illness weredischarged to the community for ongoing care
-
7/30/2019 Review 2 Final Sp2011 PDF
2/60
Cause of Revolving Door in Mental
Health
Cost of care for hospitalized psychiatric
clients continue to rise.
Individuals with severe mental illness had
no place to go when their symptoms
became worst except back to the hospital.
Lack of funding for adequate
community services
-
7/30/2019 Review 2 Final Sp2011 PDF
3/60
-
7/30/2019 Review 2 Final Sp2011 PDF
4/60
-
7/30/2019 Review 2 Final Sp2011 PDF
5/60
Primary Prevention
Primary prevention aims to prevent the
disease from occurring. So primary
prevention reduces both the incidence and
prevalence of a disease.
Encouraging people to protect themselves
from the sun's ultraviolet rays is an
example of primary prevention of skincancer.
-
7/30/2019 Review 2 Final Sp2011 PDF
6/60
Secondary Prevention
Secondary prevention is usedafter the
disease has occurred, butbefore the
person notices that anything is wrong.
A doctor checking for suspicious skin
growths is an example of secondary
prevention of skin cancer. The goal of
secondary prevention is to find and treatdisease early. In many cases, the disease
can be cured.
-
7/30/2019 Review 2 Final Sp2011 PDF
7/60
Tertiary Prevention
Tertiary prevention targets the person who
already has symptoms of the disease
The goals of tertiary prevention are: prevent damage and pain from the disease
slow down the disease
prevent the disease from causing otherproblems (These are called
"complications.")
-
7/30/2019 Review 2 Final Sp2011 PDF
8/60
Tertiary Prevention (Contd)
give better care to people with the disease
make people with the disease healthy again
and able to do what they used to do
Developing better treatments for melanoma is
an example of tertiary prevention.
Other examples include better surgeries, newmedicines, rehabilitation etc.
-
7/30/2019 Review 2 Final Sp2011 PDF
9/60
Characteristics Mental Health
Reality orientation: one characteristic of
mental health is that a person is able to
distinguish facts from fantasy, real world
from a dream world. Must have ability to
perceive reality without distortions, have a
good sense of consequences of your actions.
-
7/30/2019 Review 2 Final Sp2011 PDF
10/60
Selfawareness/Introspection
Introspection is to look inward in an effort toward self
understanding.
Recognize own feelings, possible prejudices
Two of Socrates most well-known quotes are "knowthyself" and "the unexamined life is not worth living."
Introspection
helps the nurse identify thoughts and feelings
helps the nurse learn about his/her behavior prevent barrier to communication and
understanding of patients behavior
-
7/30/2019 Review 2 Final Sp2011 PDF
11/60
What is Introspection?
Defined as: the observation or examination ofone's own mental and emotional state, mentalprocesses, etc.; the act of looking within oneself.
This implies that through introspection webecome self-aware.
The nurse needs to be aware of, understand,and consider his/her own feelings/behavior in
order to remain objective and to promotetherapeutic relationship.
-
7/30/2019 Review 2 Final Sp2011 PDF
12/60
What defines a social
relationship?
A social relationship is reciprocal, that is bothpeople expect to get their needs met.
Have something in common
It involves friendship, companionship. Boundaries are not as defined
There are not necessarily goals to be met
We may give advice, have small talk
-
7/30/2019 Review 2 Final Sp2011 PDF
13/60
Therapeutic Relationship
(Contd)
Therapeutic Relationship Goal specific
Client centered
Responsibility and reliability of nurse
Professional boundaries
Clients gain only
Clients needs are foremost
Open to supervision.
-
7/30/2019 Review 2 Final Sp2011 PDF
14/60
Introspection (Contd)
Assists the nurse in identifying herthoughts and feelings and to learn abouthis/her behavior.
It promotes understanding of clientsbehavior by preventing barriers to
interpretation.
-
7/30/2019 Review 2 Final Sp2011 PDF
15/60
Establishing Therapeutic
Relationship
-
7/30/2019 Review 2 Final Sp2011 PDF
16/60
Establishing a Therapeutic
Relationship: Orientation Phase
Meeting nurse, client
Establishment of roles
Discussion of purposes, parameters of future
meetings
Clarification of expectations
Identification of clients problems
Nurse-client contracts/confidentiality, duty towarn/self-disclosure
-
7/30/2019 Review 2 Final Sp2011 PDF
17/60
Behavior of Client During
Orientation Phase
Client May
Be distrustful, superficial, quiet, avoiddiscussion of issues
Resistance
Exaggerate problems
Have rambling speech/anxiety Act out
-
7/30/2019 Review 2 Final Sp2011 PDF
18/60
Establishing the Therapeutic
Relationship: Working Phase
Problem identification: issues or concernsidentified by client; examination of clientsfeelings and responses.
During this phase trust begins to develop
and the patient begins to respondselectively to person who seem to offerhelp.
The patient begin to identify with the nurse
and identify problems, which can beworked on
-
7/30/2019 Review 2 Final Sp2011 PDF
19/60
Therapeutic Roles of the
Nurse in a Relationship
Teacher identifying needs of pt.(coping, problemsolving, medication regimen, communityresources)
-
7/30/2019 Review 2 Final Sp2011 PDF
20/60
Definition of a Scientific Theory
A theory comprises of a collection of
concepts used to explain observations
-
7/30/2019 Review 2 Final Sp2011 PDF
21/60
Harry Stack Sullivan, a psychiatrist
He thought that inadequate or non-satisfying relationshipproduce anxiety and is the basis for all emotionalproblems
Sullivan thought that human nature must be understoodfrom the vantage point of interpersonal relations.
He believed that the development of self concept isinfluence by reflected appraisal.
The term reflected appraisal refers to a processwhere we imagine how other people see us. The waywe believe others perceive us is the way we perceiveourselves.
The self is the sum of reflected appraisals of others.
Interpersonal/Social Psychology
Theories
-
7/30/2019 Review 2 Final Sp2011 PDF
22/60
Erik Erikson
The new Ego.
Erikson believed that the Ego Freud described was far
more than just a mediator between the superego and the
id.
Erikson saw the Egos main job was to establish and
maintain a sense of identity. (a sense of belonging).
Erikson developed stages of psychosocial development.
The inability to complete the first stage of Trust Vs.Mistrust may result in anxiety, heightened
insecurities, and an over feeling of mistrust in the
world around him/her.
-
7/30/2019 Review 2 Final Sp2011 PDF
23/60
Eriksons Theory
Autonomy vs. Shame & Doubt
This is the stage of I am what I can do. The child egoskills continue to develop along with his/herwill
powerand self control. If a person develops a low self-esteem accompanied
by secretiveness. This person has not completed theautonomy vs. shame & doubt stage and needs tocomplete this stage before moving on to the other
stage of development. Initiative vs. Guilt (preschool) development of
conscience learning to manage conflict and anxiety.Continuation of autonomy.
-
7/30/2019 Review 2 Final Sp2011 PDF
24/60
Eriksons Theory
Industry versus inferiority
Taking pleasures in his/her competence. Developing
confidence in his/her abilities. Failure to complete this
stage the child becomes a conformist and thoughtlessperson who others exploit . The person develops an
inferiority complex.
Identify vs. role confusion (adolescence)
Prior to this stage, development depends onwhat is done to the person.
-
7/30/2019 Review 2 Final Sp2011 PDF
25/60
Defense Mechanism
An ego defense mechanism becomes
pathological only when its persistent use
leads to maladaptive behavior such that the
physical and/or mental health of theindividual is adversely affected.
The purpose of the ego defense mechanisms
is to protect the mind/self/ego from anxiety.
-
7/30/2019 Review 2 Final Sp2011 PDF
26/60
Levels of Anxiety
Definition of Anxiety: is a state of dread,unpleasant feeling which leads to increased
helpless feeling. There are four levels of anxiety
Mild, Moderate, Severe,Panic
The nurse intervention must include:
Reducing the anxiety to a lower level
Observing the anxiety and identify the level
Inform the patient what is being done.
-
7/30/2019 Review 2 Final Sp2011 PDF
27/60
Levels of Anxiety
MENTAL HEALTH NURSING:
Psychiatric Disorders
Mild
Associated with the tension of everyday life
The individual is alert The perceptual field is increased
Ability to learn is increased
Effective problem solving
S & S: Restlessness, fidgeting, buttterflies, sleep
disturbance, hypersensitive to noise.
-
7/30/2019 Review 2 Final Sp2011 PDF
28/60
Anxiety Levels
Mild (Contd) Intervention: generally requires no direct intervention.
keep the clients anxiety level from escalating.
Assist the client to identify the event or situation that
preceded the symptoms of anxiety. Help the client to problem solve.
Assist the client to slow breathing rate and depth.
On Long term basis assist client to problem solve todecrease stress and anxiety
Assess the thoughts and feelings prior to the anxiety(i.e., what cause the anxiety).
Note anxiety is very contagious
Teaching can be very effective when there is mildanxiety.
-
7/30/2019 Review 2 Final Sp2011 PDF
29/60
Obsessive-Compulsive Disorder
Obsessions((the thinking aspect) are recurrent,persistent, intrusive, and unwanted thoughts,images,or impulses that cause marked anxietyand interfere with interpersonal, social, or
occupational functioning.e.g. obsessed with contamination
Compuls ions(the acting aspect) are ritualistic orrepetitive behaviors or mental acts that a person
carries out continuously in an attempt to neutralizeanxiety.e.g. compulsion - repetitive hand washing
-
7/30/2019 Review 2 Final Sp2011 PDF
30/60
Nursing Process for OCD
Intervention (Contd)
Assist client to identify events that increase
their rituals.
Plan schedule around clients rituals
Allow the client to perform the rituals but setlimits.
Be supportive to the client but limit the
behavior Protect client from harmful rituals e.g., give
gloves if the ritual is washing hands 90
times/day.
-
7/30/2019 Review 2 Final Sp2011 PDF
31/60
OCD (Contd)
Important Nursing Implication: The
nurse must understand that the client
recognize that his/her symptoms are
unacceptable or foolish
-
7/30/2019 Review 2 Final Sp2011 PDF
32/60
SOMATOFORM DISORDERS
Is a mental disorder characterized by physical
symptoms that suggest a medical condition.
Upon physical examination, the findings are
negative. Usually occurs before age 30. Client will talk
about multiple vague physical complaints
involving various parts of the body or various
body systems.
It is a chronic disorder
-
7/30/2019 Review 2 Final Sp2011 PDF
33/60
SOMATOFORM DISORDERS
Onset and Clinical Course:
Symptoms usually onset in adolescence or early
adulthood
All the somatoform disorders are either chronicor recurrent
Clients will go from one physician or clinic to
another, or they may see multiple providers atonce in an effort to obtain relief of symptoms
-
7/30/2019 Review 2 Final Sp2011 PDF
34/60
Somatoform Disorder
Intervention
Providing health teaching about the
manifestation of the disorder
Establishing a firm therapeutic alliance,( that
is, a therapeutic relationship between the
nurse/therapist and the client)
Providing consistent reassurance to client Evaluate any new complaints
-
7/30/2019 Review 2 Final Sp2011 PDF
35/60
Conversion Disorder
Conversion disorder: unexplained deficits in sensoryor motor function associated with psychologicalfactors;
The client display a lack of concern towards the
physical symptoms. This is called la belleindif ference. It is believed the physicalsymptoms may relieve anxiety and result insecondary gains in the form of sympathy and
attention given by others.Primary gain is the relief of the emotional
conflict/anxiety.
Secondary gain is attention getting from others.
-
7/30/2019 Review 2 Final Sp2011 PDF
36/60
Somatoform Disorders -Nursing
Conversion - Intervention
Meet the dependency needs that is, take care
of client physical needs, eg. paralysis,
perform ROM exercises of the limb.
Never imply the symptoms are not real Dont react to the client indifference (la Belle
Indifference)
Teach stress reduction and assertiveness
Be positive,make sure the client has a positive
feelings and has positive outcomes.
-
7/30/2019 Review 2 Final Sp2011 PDF
37/60
SYMPTOMS OF SCHIZOPHRENIA
Types of symptoms
Negative symptoms
Positive symptoms
-
7/30/2019 Review 2 Final Sp2011 PDF
38/60
SCHIZOPHRENIA NEGATIVE
SYMPTOMS
Soft or negative symptoms include:
Affect is an outward manifestation of feelings or
emotions.
Affect may be flat, blunt, labile inappropriate
Flat Affect Absence of any facial expression
that would indicate emotions or mood.
Blunted Affect showing little or slow to respond
with facial expression or no facial expression, voice
monotone and no eye contact.
-
7/30/2019 Review 2 Final Sp2011 PDF
39/60
SCHIZOPHRENIA NEGATIVE
SYMPTOMS (Contd)
Labile Affect rapidly changing, unstable
and fluctuating emotions. May not fit
the situation with content and speech Apathy (lack of emotional involvement) -
the patient has build a wall of indifference
around himself.
Inappropriate incongruency between the content ofthe speech and the expressed emotion.
-
7/30/2019 Review 2 Final Sp2011 PDF
40/60
SCHIZOPHRENIA POSITIVE
SYMPTOMS - Defense Mechanism -
Projection
Hallucinations are distortions orexaggerations of perception in any of the
senses that do not exist in realtiy. E.g.
auditory hallucinations (hearing voices) -
visual hallucinations.
-
7/30/2019 Review 2 Final Sp2011 PDF
41/60
Hallucination and Defense
Mechanism
Hallucination and defense mechanismprojection:
Auditory hallucination means when there is
no one talking to the patient, the patientperceives that some one else is talking tohim. This is projection.
The patient is projecting unacceptable
feelings onto some one else. Forexample,The voice told me to kill the nonbelievers..
SCHIZOPHRENIA POSITIVE
-
7/30/2019 Review 2 Final Sp2011 PDF
42/60
SCHIZOPHRENIA POSITIVE
SYMPTOMS (Contd)
Delusions - fixed false beliefs that have no basis in
reality.
Delusions defend against feelings, impulses or ideas
that cause client anxiety. Delusions of being followed or watched are common,
as are beliefs that comments, radio or TV programs,
etc., are directing special messages directly to
him/her. Eg. FBI
Short term goal for delusional client: That the
patient will report decreased frequency of
delusional thoughts.
-
7/30/2019 Review 2 Final Sp2011 PDF
43/60
DELUSIONAL DISORDERS
Grandiose: People are convinced that
they have some great talent or have made
some important discovery. The grandiosity
is a symptom of low self esteem.
Nursing Outcome: Patient self-esteem
will increase
-
7/30/2019 Review 2 Final Sp2011 PDF
44/60
Antipsychotic Side Effects mostly of
conventional antipsychotics drugs
Tardive dyskinesia (TDs) are involuntary
movements of the tongue lips, (sucking,
chewing and pursing movements of the
tongue and mouth) face, trunk and extremitiesthat occurs in patient treated with long term
dopaminergic antagonist medications.
Is common in patients with schizophrenia,
schizoaffective d/o and bipolar disorder.Treatment: cogentin, haldol, benadryl
S
-
7/30/2019 Review 2 Final Sp2011 PDF
45/60
Schizophrenia Maintenance
Therapy
Three antipsychotics meds are available in depot
injection forms for maintenance therapy:
Fluphenazine (Prolixin) in decanoate and
enanthate preparationsHaloperidol (Haldol) in decanoate
RISPERDAL CONSTA
The effects of the medications last from 2 to 4 weeks,
eliminating the need for daily oral antipsychoticmedication
The medication improve patient compliancewith treatment.
-
7/30/2019 Review 2 Final Sp2011 PDF
46/60
Antisocial Personality Disorder -
Characteristics
Very charming, cunning, superficial and veryaggressive in meeting their needs.
Adept at getting his way at the expense ofothers
Feelings of boredom which leads to impulsivityand irresponsibility
No blame or guilt acceptance
Lack definite goals. Lots of restlessness Impaired ability to sustain long lasting close,
warm responsible relationship.
A ti S i l P lit D/O
-
7/30/2019 Review 2 Final Sp2011 PDF
47/60
Anti Social Personality D/O
Intervention
Provide structure and limit setting
Point out the unacceptable behavior.
Be direct and consistent about the
statement of the behavior.
Point out the consequences of the
unacceptable behavior and follow
through consistently.
-
7/30/2019 Review 2 Final Sp2011 PDF
48/60
Characteristics Of Client With
Personality Disorder
Personality Disorder is characterized by
inflexible behavior pattern that causes
problem in functioning and relationship.
It is a maladaptation to interpersonal
interaction and social environment or
context (i.e. how the client viewed things,
objects, situations)
-
7/30/2019 Review 2 Final Sp2011 PDF
49/60
Personality Disorders
Borderline Personality Disorder
Assessment:
Patients often has dysphoric mood( feeling of
unhappiness, emotional lability)
Dependency
Display impulsive behavior
Splitting, Over- idealization and devaluing
Experience suicidal feelings
Complains of feeling of emptiness,
suspiciousness and loneliness
-
7/30/2019 Review 2 Final Sp2011 PDF
50/60
Borderline Personality Disorder
(Contd)
Intervention
Monitor for suicidal gestures because client
generally feel abandon and suicidality is a great
risk factor
-
7/30/2019 Review 2 Final Sp2011 PDF
51/60
Individual Psychotherapy
Modifies a persons feelings, attitudes,and behavior
Involves one-on-one work between patient
and therapist. Allows the patient to have the full attention
of the therapist
Is limited - it does not allow the therapistan opportunity to observe the patientwithin social or family relationships.
-
7/30/2019 Review 2 Final Sp2011 PDF
52/60
ETOH Withdrawal
Usually begins 4-12 hours after cessation or
marked reduction of ETOH.
Symptoms: coarse hand tremors, sweating,
elevated pulse and BP, insomnia, anxiety, N&V May progress to hallucination, seizures,
illusion, gross tremors and delirium tremens
(DTs)
Treatment: benzodiazepines to prevent
seizures
-
7/30/2019 Review 2 Final Sp2011 PDF
53/60
Major Depression Disorder
Involves 2 or more weeks of sad mood, lack ofinterest in life activities (anhedonia), and at leastfour (4) other symptoms:
Changes in appetite or weight, sleep, or psychomotor
activity Decreased energy (persistent fatigue)
Feelings of worthlessness, hopelessness
helplessness
Persistent feeling of guilt or self-criticism Persistent sadness
-
7/30/2019 Review 2 Final Sp2011 PDF
54/60
Major Depressive Disorder
Intervention
Provide for the clients safety and the safety ofothers
Promote a therapeutic relationship bymaintaining planned contact with patient.
Establish daily schedule of activities
Structure activities to facilitate completion of one
specific task. Sit silently with patient when patient is not too
communicative
Promote activities of daily living and physical care
-
7/30/2019 Review 2 Final Sp2011 PDF
55/60
Treatment (Contd)
TCAs: amitriptyline (elavil), imipramine (tofranil),moderate and severe depression. Their onset of actionis 1-4 weeks. i.e., they take 1-4 weeks before the clientsymptoms begin to decrease.
Have anticholinergic side effects: blurred vision,dry mouth, constipation).
MAOIs (marplan, parnate, nardil) used infrequentlybecause interaction with tyramine causes hypertensivecrisis.
TCAs and MAOIs cannot be given concurrently The primary side effect is hypertensive crisis if the
drug is taken with food containing tyramine
-
7/30/2019 Review 2 Final Sp2011 PDF
56/60
Bipolar Disorder
Assessment
Some people with mania exhibit psychoses e.g
delusions (unshakable beliefs in something untrue)
and/or hallucinations.
Some get hostile and aggressive if they needs are not
met.
Hyperactive, disorganized and has an elevated mood.
Easily stimulated by what is going on around him/her.
For how much the client is eating and sleeping
-
7/30/2019 Review 2 Final Sp2011 PDF
57/60
Bipolar Disorder (Contd)
Assessment
Major symptoms of mania include:
Inflated self-esteem or grandiosity
Decreased need for sleep Psychomotor agitation
Pressured speech
Flight of ideas
Distractibility
Euphoria, labile mood
-
7/30/2019 Review 2 Final Sp2011 PDF
58/60
Bipolar - Treatment
LITHIUM CARBONATE
Treatment and Prognosis - Medication
Treatment involves a lifetime regimen of
medications Lithium; regular monitoring of serum lithium levels is
needed.
Lithium not only competes for salt receptor sites butalso affects calcium, potassium and magnesium ionas well as glucose metabolism.
Therapeutic level 0.5-1.5 mEq/L
-
7/30/2019 Review 2 Final Sp2011 PDF
59/60
Bipolar Treatment (Contd)
Lithium (Contd) Nursing Implication: Teach patient to maintain
adequate salt in the diet.
If patient is toxic, hold medication and report to MD
Anticonvulsant drugs are used for their mood-stabilizingeffects:
Depakote therapeutic level 50-100 mcg/ml.
Side effect: Weight gain, agranulocytosis
Tegretol therapeutic level 6-12 mcg/ml
Side effects:agranulocytosis, thrombocytopenia,aplastic anemia
-
7/30/2019 Review 2 Final Sp2011 PDF
60/60
Bipolar Disorder
Intervention
Providing for safety of client and others
Meeting physiologic needs
Providing therapeutic communication Promoting appropriate behaviors
Managing medications
Providing client and family teaching
Set limits on intrusive or interruptive behaviors.