DSM-V intervention

• this a multiaxial diagnostic system for psychiatric disorder and general medical conditions, social and environmental problems and level of functioning
• it provides a convenient format for organizing and communicating clinical information, for capturing the complexity of clincial situation and for describing the heterogeneity of individuals presenting with the same diagnosis
• the new DSM-V is no longer multiaxial and has many changes in diagnostic categories. many clinician have not accepted it into their practice yet. you may still see the multiaxial diagnoses on pt charts. NOTE this publication is politically influenced and insurance cost driven

• Axis L- clinical disorders and other conditions that may be a focus of clinical attention, excluding Personality disorder and mental retardation
• Axis II- personality disorders and mental retardation
• Axis III- general medical condition- current medical conditions that are potentially relevant to the understanding or management of the individual's mental disorder

• Axis IV- psychosocial and environmental problems that may affect and diagnosis, treatment and prognosis of mental disorders (presen during the yr prior to the present evaluation)
• included are:
• problems w/primary support group- eg death of the family member, health problems in the family, disruption of the family by separation, divorce, or estrangement, etc
• problems related to the social environment eg death or loss of a friend, inadequate social support, living alone, discrimination etc

• Educational problems- illiteracy, academic problems, discord with teacher
• occupational problems- unemployment, threat of job loss,stressful work schedule, discord with boss co-workers
• housing problems- homelessness, unsafe neighborhood, etc
• economic problems- extreme proverty, inadequate finances, etc
• problems w/access to health care services- inadequate health care services, inadequate health insurance
• problems r/t interaction with the legal system-arrest, incarceration, victim of crime etc
• other psychosocial and environmental problems- exposure to disasters, war, other hostilities etc

• Axis V- global assessment of functioning (GAF) is for reporting the clinician's judgement of the individual's overall level of functioning
• this info is useful in planning tx and measuring its impact and in predicting outcomes
• it is to be rated with respect only to psychological, social, and occupational functioning, not impairment in functioning due to physical or environmental limitations

• intelligence tests- designed to evaluate intellectual and cognitive abilities. includes Weschsler Adult Intelligence Scale (WAIS) and the Wechsler Intelligence Scale for children (WISC)
• these test have been classically standardized on white middle- class populations, which leads to questionable reliability and validity with other cultural groups

usually administered by clinical psychologists. focus is on aspects of personality function (includes reality testing ability, impulse control, major defenses, interpersonal conflicts, and self control). Mulitple test are usually administered to obtain a comprehensive picture. test include: the Rorschach (ink blot) Test, Thematic Apperception Test (TAT), pictures from which clients can tell a story and Minnesota Multiphasic Personality Inventory (MMPI) well designed to pick up personally traits and can detect lying on test

• while it is impossible to measure psychiatric illness directly, it is feasible to measure behavioral indicators of adaptive or maladaptive responses to the illness
• research has shown:
• measure the extent of the client's problem
• make an accurate diagnoses
• track pt progress over time
• document the efficacy of tx
• - ie 3 times refuse meds- document everything

• the behavioral rating scales do not replace required nursing documentations, but provide measurable, evidence-based indicators of tx outcomes
• - client take the scales at the beginning of tx and periodically thereafter. progress is measured by changes in scores )or maintenance of scores)
• scales used should also be assessed for their validity and reliabilty

• abnormal involuntary movement scale (AIMS) a 5-10 min scale to assess for tardive dyskenesia, is utilized before instituting pharmacotherapy and then every - mos after
• Edinburgh Postnatal Depression Scale (EPDS)- is a valid screening tool for detecting postpartum depression (as differentiated from postpartum blues and psychosis)
• bipolar disorder and previous postpartum psychosis increase risk for suicide or infanticide
• short version of geriatric depression rating scale
• mini mental state exam
• beck's depression scale
• Yale-BRown Obsessive-compulsive scale
• Hamiliton anxiety scale & hundreds of others

• or therapeutic communication
• 'scientific structuring of the environment to effect behavioral changes to improve the psychological health and functioning of the individual'
• within the therapeutic community setting, the client is expected to learn adaptive coping and interaction and relationship skills that can be generalized to other aspect of his or her life
• caring calm therapeutic environment

• environment affects behavior and with a safe structured environement optimal functioning can be developed
• the purposeful use of people, resources and event can improve interpersonal skills while valuing the pt's rights
• care should be given to avoid excessive noise, violence, inapproriate books and movies
• verbal or physically threats and disruptive patients behaviors must be addressed immediately
• take these skills to live their lives

• restriction and punishment should be avoided
• lighting, temperature and personal space important
• the client owns their own environemnt
• the client owns their own behavior
• each client has the right to be acknowledged grow and supported
• every interaction is an opportunity fir therapeutic intervention

• consist of psychiarist, clinical nurse specialist, mental health nurses, clinical psychologist, community health nurse, social workers, occupational therapist, mental health counselors, and pt advocates and the pt
• effective tx calls for a combo of different experts in varies areas, utilzing a discipline specific perspective to tackle complex cases. this collab will provide for a more holstic plan for client

• to assist with the patient's successful adaption to stressors within the environment
• work with teams and pt to make sure goals are directed towards chx in thoughts, feeling and behaviors that are age-approriate and congruent with local and cultural norms
• valuable member of the team, providing a service that is unique and based on sound knowledge of psychopathology, scope of practice and legal implication of the role

• Phase one- pre interaction phase
• - obtain info about client from chart, significant other or other health team members
• - examine one;s own feelings, fears and anxieties about working with a particular client
• Phase two- orientation (introductory) phase
• - create an environment for trust and rapport
• - esta contract from intervention
• - gather assessment data
• - identify client's strength and limitations

• working phase
• - maintain trust and rapport
• - promote client's insight and perception of reality
• - use problem-solving or recovery model to work toward achievement of esta goals
• - overcome resistance behaviors
• - continuosly evaluate progress toward goal attainment

• termination phase
• therapeutic conclusion of relationship occurs when:
• - progress has been made toward attainment of the goals
• - a plan of action for more adaptive coping with future stressful situations has been established
• - feelings about termination of the relationship are recognized and explored

• transference: occurs when a patient unconsciously displaces (or transfer) to the nurse feelings formed  toward a person from the past. can be displayed though anger towards nurse or overwhelming feelings of affection and dependency
• countertransference: refers to the nurse's behavioral and emotional response to the pt. nurse can over identify with pt, based on her own past experience. nurse may defend, have difficulty seeing limits, feels anxious or even have feelings or disgust for patient

• agreeing or disagreeing (check your own comfort level)
• giving advice
• probing 9asking to describe trauma
• defending
• belittle (using humor)
• asking whu
• interpreting
• changing topic
• asking them not to cry
• telling them not to worry

• remember to be aware of non verbal communication
• physical appearance and dress
• body movement and posture
• touch & space
• facial expressions
• eye behavior
• vocal cues or paralanguage
• also be aware of distance, gender roles,pre-existing cultural bias & the environment or climate where communication is being done

• is culturally determined. can conflict with verbal, much is unconscious and is loaded with emotions
• types: touch, body position, movements, facial expression, gestures, timing spacing
• what skills were used?
• what challenges would patient with perceptual or cognitive impairments face
• drawing can be very effective communicator

• orignating from the addiction field, currently utilized in many mental health setting, since it is now believed that recovery from mental illness is possible. models are intergrating into philosphy of tx
• provide for a process of chx thru which the individuals improve their health and wellness, learn to live a self-directed life and strive to reach their fullest potential
• deeply personal unique process that empowers the pt to own control over their life path

• transparency: tx is discuss openly and is pt centered in q aspect
• recovery emerges from hope and it is holstic involving by peers, family & community
• recovery is based on respect and cultural/spiritual awareness
• the recovery is fluent & involves many pathways

• well within the scope of nursing practice to assess pt in recovery process
• nurses are specifically educated to recognize and respond to the need for help- peplau
• as nurse we are the best at utilizing all aspects of service delivery systems and responsible for the delivery & coordination of care
• nurses will play a key role into the development and implementation of pt recovery actions plans