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Addressing Higher-Level Needs in
Psychiatric Clients
Essentials of Psychiatric Mental Health
Nursing: Concepts of Care in Evidence-Based
Practice
Chapter 1. Mental Health and Mental Illness
Assessing Client Behaviors :
The client's behaviors demonstrate no functional impairment, indicating no mental illness. The client is experiencing occasional feelings of sadness due to the recent death of a beloved pet, but their appetite, sleep patterns, and daily routine have not changed. This response is within normal expectations and does not indicate the presence of mental illness.
Determining Risk for Mental Illness :
The nurse should determine that the client is at risk for mental illness when maladaptive responses to stress are coupled with interference in daily functioning. The DSM-5 criteria indicate that for a mental illness diagnosis, daily functioning must be significantly impaired.
Stress Responses in Identical Twins :
The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. Mental health is a state of being that is relative to the individual client. Environmental influences and temperament can affect stress reactions, leading to different responses in identical twins.
Client Receptiveness to Psychiatric Treatment :
The nurse should anticipate that the Jewish, female social worker would be most receptive to psychiatric treatment. This is because individuals of Jewish culture often place a high importance on preventative health care and consider mental health as equally important as physical health. Women are also more likely to seek treatment for mental health problems than men.
Evaluation of Defense Mechanisms :
The nurse should determine that defense mechanisms can be appropriate responses to stress and need not be eliminated. Defense mechanisms can help the client manage anxiety, and eliminating them may lead to a lower tolerance for stress and the development of anxiety
disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.
Addressing Client Resistance to Psychosocial Questions :
The nurse's best response is to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment.
Displacement as a Defense Mechanism :
When the employee uses the defense mechanism of displacement, the expected behavior would be that the employee leaves the staff meeting to work out in the gym. Displacement involves redirecting emotions or impulses from their original source to a less threatening target.
Psychological Defense Mechanisms
Displacement
The employee criticizes a coworker after being confronted by the boss. This is an example of the defense mechanism of displacement, where feelings are transferred from one target to a neutral or less-threatening target.
Reaction Formation
A fourth-grade boy teases and makes jokes about a cute girl in his class. This behavior should be identified as indicative of the defense mechanism of reaction formation, where the boy is attempting to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors.
Neurosis
An individual experiencing neurosis feels helpless to change their situation, is aware that they are experiencing distress, and is aware that their behaviors are maladaptive, but is unaware of the psychological causes of the distress and experiences no loss of contact with reality.
Psychosis
Individuals experiencing psychoses experience little distress due to their lack of awareness of reality. They are unaware that their behavior is maladaptive or that they have a psychological problem.
Biological Implications
Biological Factors in Depression
Medications address biological factors, but environmental and interpersonal factors must also be considered in the treatment of depression.
Limbic System and Emotions
The limbic system is largely responsible for one's emotional state and is often called the "emotional brain".
Sympathetic Nervous System and Stress
The sympathetic nervous system plays a major role during stressful situations, preparing the body for the fight-or-flight response.
Circadian Rhythms and Psychopathology
Circadian rhythms may influence a variety of regulatory functions, including the sleep-wake cycle, regulation of body temperature, and patterns of activity.
Adoption Studies and Genetics
Adoption studies can provide useful information for the psychiatric community by revealing research findings relating genetic links to mental illness.
Psychoimmunology and Stress
Psychoimmunology studies the effects of social and psychological factors on the functioning of the immune system, and hypothesizes that individuals become more susceptible to physical illness following exposure to stressful stimuli.
Neurotransmitters and Schizophrenia
Neurotransmitters play an essential function in the role of human emotion and behavior, and are targeted and affected by many psychotropic medications.
Neurotransmitters and Their Processes
Reuptake of Neurotransmitters
The process by which neurotransmitters are released into the synaptic cleft and returned to the presynaptic neuron is termed reuptake. Reuptake is the process by which neurotransmitters are stored for reuse.
Neurotransmitters and Physiological Responses
Norepinephrine and the Fight-or-Flight Response
The neurotransmitter norepinephrine is associated with the fight-or-flight response. Norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and is involved in the regulation of mood, cognition, perception, locomotion, and sleep and arousal.
Dopamine and Schizophrenia
Elevated dopamine levels may be an attributing factor in the development of catatonic schizophrenia. Dopamine functions include the regulation of movements and coordination, emotions, and voluntary decision-making ability.
Neurotransmitters and Mental Illness
Decreased Prolactin and Schizophrenia
There may be a correlation between decreased levels of the hormone prolactin and schizophrenia , although the exact mechanism is unknown.
Decreased Acetylcholine and Memory/Motor Deficits
Decreased levels of acetylcholine are correlated with memory deficits and decreased motor function. Acetylcholine is involved in sleep regulation, pain perception, the modulation and coordination of movement, and memory.
Decreased Norepinephrine and Major Depressive Disorder
A decrease in norepinephrine levels plays a significant role in the development of major depressive disorder. Norepinephrine regulates mood, cognition, perception, locomotion, cardiovascular functioning, and sleep and arousal.
Increased Dopamine and Schizophrenia Spectrum Disorder
An increase in dopamine activity might play a significant role in the development of schizophrenia spectrum disorder. Dopamine functions
The nurse has violated the ethical principle of veracity by tricking a client into seclusion. The principle of veracity refers to one's duty to always be truthful and not intentionally deceive or mislead clients.
The nurse should question the validity of informed consent when the client incorrectly reports their spouse's name, date, and time of day, as this indicates the client may not be competent to make informed choices.
Medication Administration
It is ethically appropriate for the nurse to allow the client to decline medication and provide accurate documentation. The client's right to refuse treatment should be upheld, unless the refusal puts the client or others in harm's way.
The nurse has committed both assault and battery by threatening to tie down the client and then doing so against the client's wishes. Assault refers to an action that results in fear and apprehension that the person will be touched without consent, and battery is the touching of another person without consent.
Restraints and Seclusion
The least-restrictive alternative for a confused, wandering geriatric client would be monitoring by an ankle bracelet. The client does not pose a direct dangerous threat to self or others, so neither physical restraints nor seclusion would be justified.
Legal Considerations
The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit without proper consent from the client.
The physician could consider involuntary commitment when a client is dangerous to others, gravely disabled, or is suicidal. If the physician determines the client is mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator.
Rights and Ethics
A right is a valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or a service.
Ethics is a branch of philosophy that deals with systematic approaches to distinguishing right from wrong behavior. Bioethics is the term applied to these principles when they refer to concepts within the scope of medicine, nursing, and allied health.
Atypical Antipsychotics
Characteristics of Atypical Antipsychotics
Atypical antipsychotics:
Produce fewer extrapyramidal side effects (EPS) compared to typical antipsychotics. Do not provide evidence that they remain in the system longer or act more quickly to reduce delusions. Are not risk-free for neuroleptic malignant syndrome (NMS).
The reduced EPS is due to less D2 receptor blockade by atypical antipsychotics.
Neuroleptic Malignant Syndrome (NMS)
Assessing for NMS
The cardinal sign of NMS is an increased temperature, typically 104°F or higher. Other signs and symptoms may include:
Decreased blood pressure Respiratory rate of 24 respirations per minute Pulse rate of 70 beats per minute
Anticholinergic Effects of Antipsychotics
Fluphenazine (Prolixin) and Anticholinergic Effects
Fluphenazine, a typical antipsychotic, can cause anticholinergic effects such as:
Dry mouth Blurred vision Constipation
These effects are due to the blockade of cholinergic receptors.
Tardive Dyskinesia (TD)
Behaviors Characteristic of TD
Behaviors that would be assessed as displaying characteristics of TD include:
Grimacing and lip smacking
Lithium Therapy
Dietary Considerations with Lithium
Patients taking lithium must be instructed that changing their dietary salt intake can affect lithium levels. Reducing salt intake can result in lithium toxicity, while increasing salt intake can cause lower lithium levels.
Benzodiazepines
Characteristics of Benzodiazepines
Benzodiazepines have a rapid onset of peak action and enhance the activity of GABA, rather than reducing its availability or generally diminishing its activity.
Withdrawal Concerns with Benzodiazepines
Shorter-acting benzodiazepines, such as alprazolam (Xanax), are more difficult to taper and can potentially cause more problems with withdrawal compared to longer-acting benzodiazepines.
Contraindications to Lithium Therapy
Lithium is contraindicated during pregnancy due to its teratogenic effects. Other conditions, such as recovering from a hysterectomy or displaying symptoms of postpartum depression, would not be contraindications to lithium therapy.
SSRI Administration Timing
SSRIs prescribed for poststroke depression are often given at breakfast and again at midday to prevent insomnia, as CNS stimulants may cause insomnia if given late in the day.
Lithium Toxicity
The priority nursing action for a patient experiencing symptoms of moderate lithium toxicity, such as coarse hand tremor, diarrhea, vomiting, lethargy, and mild confusion, is to hold the lithium, obtain a stat lithium level, and notify the physician.
Rapid Cycling Bipolar Disorder
For a patient with rapid cycling bipolar disorder not responding well to lithium, the nurse should inform the patient that valproic acid is a first-line agent proven effective for the treatment of rapid cycling bipolar disorder.
Benzodiazepine Use in Generalized Anxiety
Disorder
A patient with generalized anxiety disorder who understands the purpose of their as-needed (prn) lorazepam (Ativan) medication is one who states that they can talk with their therapist more easily after the medication takes effect.
Extrapyramidal Side Effects (EPS) of Typical
Antipsychotics
The behaviors of drooling, hand tremors, and a shuffling gait displayed by a patient taking chlorpromazine (Thorazine) for 2 weeks are symptoms of pseudoparkinsonism associated with dopamine blockade, a common EPS of typical antipsychotics.
Side Effects of Valproate Therapy
The nurse should request a histamine-2 antagonist, such as famotidine (Pepcid), for a patient reporting gastrointestinal side effects related to valproate therapy, as indigestion, heartburn, and nausea are common side effects of this medication.
Lithium Toxicity Assessment
If a patient's serum lithium level is reported as 1.9 mEq/L, the nurse should immediately assess the patient for signs and symptoms of lithium toxicity, as this high level suggests the patient may be experiencing toxicity.
Evaluating Outcomes of Typical Antipsychotic
Therapy
To evaluate outcomes for a patient with schizophrenia receiving typical antipsychotic drug therapy, the nurse would look for improvement in the patient's positive symptoms, such as delusions and hallucinations.
Self-care Activities
Cognitive Functioning
Typical antipsychotic medications are known to produce improvement in the positive symptoms of schizophrenia, such as hallucinations and delusions. However, negative symptoms and cognitive functioning tend to show less improvement with these medications.
treatment goals. Rapport implies feelings on the part of both the nurse and the client, based on respect, acceptance, a sense of trust, and a nonjudgmental attitude.
4. Gaining Insight and Incorporating Alternative Behaviors
The nurse should expect that the client will gain insight and incorporate alternative behaviors during the working phase of the nurse-client relationship. The client may also overcome resistance, problem-solve, and continually evaluate progress toward goals.
5. Overcoming Resistance to Discussing Painful Issues
The client statement, "I really don't want to talk any more about my childhood abuse," reflects that the client is in the working phase of the nurse-client relationship. The working phase includes overcoming resistance behaviors on the part of the client as the level of anxiety rises in response to discussion of painful issues.
6. Conveying Empathy
The nurse's response, "It must be horrible to lose a child, and I'll stay with you until your husband arrives," conveys empathy to the client. Empathy is the ability to see the situation from the client's point of view and is considered to be one of the most important characteristics of the therapeutic relationship.
7. Identifying Lack of Genuineness
When an individual is two-faced, which means double-dealing or deceitful, the nurse should identify that genuineness is missing in the relationship. Genuineness refers to the nurse's ability to be open and honest and maintain congruence between what is felt and what is communicated.
8. Promoting the Client's Insight and Perception of Reality
The nurse should place priority on promoting the client's insight and perception of reality during the working phase of relationship development.
9. Using the Therapeutic Communication Technique of
Restatement
The nurse is using the therapeutic communication technique of restatement, which involves repeating the main idea of what the client has said. It allows the client to know whether the statement has been understood and provides an opportunity to continue.
10. Using the Therapeutic Communication Technique of
Formulating a Plan of Action
The nurse is using the therapeutic communication technique of formulating a plan of action to help the client explore alternatives to drinking. The use of this technique may serve to prevent anger or anxiety from escalating.
11. Offering a General Lead
The nurse's statement, "Yes, I see. Go on," is an example of a general lead, which encourages the client to continue sharing information.
12. Giving Reassurance
The nurse's statement, "Things will look better tomorrow after a good night's sleep," is an example of the nontherapeutic communication technique of giving reassurance. Giving reassurance indicates to the client that there is no cause for anxiety, thereby devaluing the client's feelings.
13. Using Broad Openings
The nurse's statement, "What would you like to talk about?" is an example of the therapeutic communication technique of a broad opening. Using broad openings allows the client to take the initiative in introducing the topic and emphasizes the importance of the client's role in the interaction.
14. Maintaining an Open Posture
The nurse's maintaining an uncrossed arm and leg posture when communicating with a client is nonverbal behavior that reflects the "O" in the active-listening acronym SOLER, which stands for sitting squarely facing the client, observing and open posture, leaning forward toward the client, establishing eye contact, and relaxing.
15. Providing Effective Feedback
The instructor's statement, "Surely you didn't do this deliberately, but you breeched confidentiality by using names," is an example of effective feedback. Feedback should be descriptive, specific, and directed toward a behavior that the person has the capacity to modify and should impart information rather than offer advice.
16. Giving Critical Information
The purpose of providing appropriate feedback is to give the client critical information. Feedback should not be used to give advice or evaluate behaviors.
A biker sporting an eagle tattoo on his biceps A teenage girl writing, "No one understands me"
It is estimated that about 70% to 80% of communication is nonverbal.
Rapport
The term "rapport" implies special feelings on the part of both the client and the nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non-health-related topics.
Countertransference
Countertransference refers to a nurse's behavioral and emotional response to a client. These responses may be related to unresolved feelings toward significant others from the nurse's past or they may be generated in response to transference feelings on the part of the client.
Nursing Assessment
Holistic Assessment
The assessment of clients diagnosed with psychiatric problems should provide a holistic view of the client. A thorough assessment involves collecting and analyzing data from the client, significant others, and health- care providers, which may include the following dimensions: physical, psychological, sociocultural, spiritual, cognitive, functional abilities, developmental, economic, and lifestyle.
Nursing Interventions
Nursing interventions occur independently but in concert with overall treatment team goals. Nursing interventions should be developed and implemented in collaboration with other health-care professionals involved in the client's care.
Advanced Practice Psychiatric Nurse
The advanced practice psychiatric nurse is authorized to use psychotherapy to improve mental health. This includes individual, couples, group, and family psychotherapy. Education, case management, and milieu therapy can be provided by registered psychiatric mental health nurses.
Problem-Oriented Charting
The acronym SOAPIE represents problem-oriented charting, which reflects the subjective, objective, assessment, plan, implementation, and evaluation format.
Mental Status Assessment
The MMSE, or mini mental status exam, would be the appropriate tool to use to assess the mental acuity of a client prior to and immediately following ECT.
Purpose of Gathering Client Information
The purpose of gathering client information is to enable the nurse to make sound clinical judgments and plan appropriate care.
Nursing Roles
The milieu manager implements care by scheduling client activities, interacting with clients, and maintaining a safe therapeutic environment.
Prioritizing Nursing Diagnoses
The nurse should prioritize nursing diagnoses related to their life- threatening potential. Safety is always the nurse's first priority.
Nursing Outcomes
Nursing outcomes should be derived from the diagnosis, measurable, and include a time estimate for attainment. The outcome must also be realistic for the client's capabilities.
Risk for Injury
A client receiving ECT and who is diagnosed with Parkinsonism is at risk for injury.
Developing Nursing Outcomes
Client outcomes are most realistic and achievable when there is collaboration among the interdisciplinary team members, the client, and significant others.
Disturbed Sensory Perception
The nursing diagnosis disturbed sensory perception accurately reflects the client's symptoms of hearing things that others do not.
Nursing Interventions and the Nursing
Process
Ordered Nursing Interventions
The following nursing interventions are presented in the order they would proceed through the steps of the nursing process:
Measure a client's vital signs and review past history. Determine if an antianxiety medication is decreasing a client's stress. Encourage deep breathing and teach relaxation techniques. Aim, with client collaboration, for a seven-hour night's sleep.
The text does not provide any additional information or context for these nursing interventions beyond the order in which they would be carried out.
Recognize and Document the Client's Problem
Nursing Process Steps
Assessment : Measuring a client's vital signs and reviewing past history is a nursing intervention that occurs in the assessment step of the nursing process.
Nursing Diagnosis : Recognizing and documenting the client's problem occurs in the nursing diagnosis step.
Planning : Setting a goal with client collaboration, for a seven-hour night's sleep occurs in the planning step.
Implementation : Encouraging deep breathing and teaching relaxation techniques occur in the implementation step.
Evaluation : Determining if an anti-anxiety medication is decreasing a client's stress occurs in the evaluation step.
Nursing Diagnosis
A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability. Nursing diagnoses are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes.
Milieu Therapy - Therapeutic Community
Basic Assumptions of Milieu Therapy
Every interaction is an opportunity for therapeutic intervention. Conflict should not be avoided but rather addressed and resolved.
The therapeutic community provides a structured environment that may be missing in the home environment. Promoting self-reliance is important, such as encouraging clients to request their medications at the appropriate times.
Appropriate Nursing Responses
When a client expresses anger about an issue, the nurse should use the interaction as an opportunity for therapeutic intervention. When a client brings up a concern about another client's behavior, the nurse should restate the client's feeling and develop a plan with the client to solve the problem. When a client questions the purpose of group therapy, the nurse should explain that the purpose is to learn and practice new coping skills.
Role of the Therapeutic Community
The therapeutic community provides structured programming, including a schedule of activities, interpersonal interaction, and focus on personal problems. This structured environment may be missing in the home environment, contributing to a client's decompensation after discharge.
Medication Administration
To promote self-reliance, the psychiatric nurse should encourage clients to request their medications at the appropriate times, rather than administering medications without the client's involvement.
Education Groups
Appropriate topics for education groups on an inpatient psychiatric unit include stress management, medical diagnoses, medication side effects, and the importance of medication adherence.
Family Involvement
Including the client's family in therapy within the inpatient milieu can facilitate discharge from the hospital. Family involvement may also prevent the client from becoming too dependent on the therapeutic environment.
Democratic Self-Government
A democratic form of self-government in the milieu, where clients participate in decision-making and problem-solving, contributes to client therapy by setting the expectation that all clients should be treated on an equal basis.
