-
mental status exam
objective part of assessment
-
purpose of psychiatric assessment
- 1. establish a rapport
- 2. obtain understanding
- 3. assess psychological funtioning
- 4. identify goals
- 5. perform MSE
- 6. identify behaviors, beliefs, ideas, etc to be modified to effect positive change
- 7. formulate plan of care
-
countertransference
the nurse's reactions to a client that are based on the nurse's unconscious needs, conflicts, problems, or view of the world.
-
purpose of gathering data
- understand current problem
- assess for risk factors
- assess current level of psychological funtioning and psychosocial status
-
through the assessment the nurse should identify?
- strengths and weaknesses
- usual coping strategies
- cultural beliefs and practices that may affect implementing traditional treatment
- spiritual beliefs or practices that are an integral part of your client's lifestyle
-
used to diagnose a psychiatric disorder, while a well-defined nursing
diagnosis provides the framework for identifying appropriate nursing
interventions for dealing with the phenomena a lcient with a mental
health disorder is experiencing
DSM-IV-TR
-
those who violate social norms and thus threaten (or make anxious) those ovserving them
mentally ill person
-
DSM-IV-TR classifies?
disorders that people have
-
Axis I includes
clinical disorders or other conditions that may be a focus of clinical attention
-
Axis I example
Major Depression
-
Axis II includes
personality disorders and mental retardation
-
Axis II example
dependent personality disorder
-
Axis III includes
general medical conditions
-
Axis III example
Diabetes
-
Axis IV includes
psychosocial and environmental problems
-
Axis IV example
divorce 3 months ago
-
Axis V includes
global assessment of functioning (GAF score) the highest it has been in the past year and the current
-
Axis V example
31 yr old and unable to work or respond to family and friends with a GAF score of 23 and a high of 75 in the past year
-
psychiatric mental health registered nurse - basic level
completed a nrusing program and passed the state licensure examination
-
psychiatric mental health registered nurse, certified - basic level
holds a baccalaureate degree in nursing and may become certified as a psychiatric mental health registered nurse, certified (RN,C) after acquiring experience and ongoing CE in this specialty.
-
advanced practice registered nurse - psychiatric mental health (APRN-PMH)
a licensed RN who is educationally prepared at the master's degree level in psychiatric nursing.
-
APRN-PMH, certified specialist
indicated certifed advance practice in the specialty by iether a psychiatric mental health clinical nurse specialist or a psychiatric mental health nurse practitioner (NP)
-
areas a basic level RN can practice in psych mental health
for individuals with mental health problems in various settings and perform a varietyh of roles - ie - staff nurses, case managers, nurse managers, and other nursing functions
-
RN, C - BSN
signifies that they have more experience than a beginning RN
-
APRN-PMH can practice in what areas?
clinical nurse specialist or the nurse practitioner whose education and experience in psychiatric nursing practice meet criteria established by the profession. they apply knowledge, skills, and experience autonomously to complex psychiatric mental health problems.
-
APRN-PMH, certified specialist - practices in what areas?
may be a psychotherapist, may be eliglible to write scrips, inpatient admisison privileges, third pary reimbursement, and other specialty privileges
-
the main focus of the psychiatric nurse si to?
promote and maintain optimal mental functioning, to prevent mental illness (or prevent further dysfunction) and to help cliens regain or improve their coping abilities.
-
interventions of the basic level PMH RN
- counseling, crisis intervention
- managing therapeutic environment (millieu)
- assist clients with self-care activities
- administer and monitor psychobiological treatments
- health teaching - psychoeducation
- pschiatric rehabilitation
- providing telehealth services
- working in a community-based care and outreach activites
- providing culturally relevaan health promotion and disease prevention strategies
- performing case management
- participating in advocacy
-
APRN-PMH specialist is qualified to provide?
- psycotherapy (individual, group, family, and other tx)
- prescription of pharmacological agents, ordering and interpretation of diagnostic and lab testing
- constultation-liason activities
- complementary interventions (relaxation, therapeutic touch, light therapy)
- clinical supervisory activities
- expanded advocacy activities
-
advocacy role of a nurse entails?
- protecting the rights of the clients, especially those with psychiatric disabilities
- identifying and reporting incidents of abuse and neglect
-
ways a nurse can be a patient advocate (5)
- improve their observation, listening, and communication skills
- need to develop and implement policies and procedures that affect the client's quality of care
- need to know that unaddressed, ongiong abusive or neglectful behaviors may be brought to the attention of a Protection and Advocacy (P&A) system from any source, including nurses
- can provide mental health consumers with the telephone number of the appropriate P&A system; it should be posted next to the patient's phone
- have a vital role in the administration of meds
-
ways a nurse can improve their observation, listening and communication skills
- ensure that a nursing care plan exists
- that ADL's and personal hygiene are addressed
- that bodily functions are monitored and assisted
- be sensitive to assessing consumer's comfort levels regarding noise, temperature, lighting and access to personal belongings
-
policies and procedures that affect the client's quality of care
- patient's bill of rights
- informed consent
- policies addressing confidentiality
- seclusion and restraint
- policies for reporting and providing appropriate remedies for staff abuse
-
examples of behaviors to be reported to P&A
- assault
- failure to provide appropriate mental health or medical diagnostic evaluation or tx
- financial exploitation
- failure to provide discharge planning
-
P&A is authorized to?
not authorized to?
investigate incidents of abuse and neglect of mentally ill individuals
protect nurses from retaliation from employers (reports can be anonymously though)
-
nurses responsibility regarding med admin
- ensure that the appropriate med is administered at a dose that makes sense
- immediately note side effects, and report and address them
- see that pts are provided with understandable med teaching plans
-
pharmacodynamics
action of drug on person
-
pharmacokinetics
action body has on drugs
-
neurotransmitters
monamines, amino acids, cholinergics, peptides
-
monamines
dopamine, norepinephrine, seratonin, histamine
-
amino acids
- gamma-aminobutric acid (GABA)
- glutamate
-
cholinergics
acetylcholine
-
peptides
substance P, somatostatin, neurotensin
-
dopamine effects
attention, motivation, pleasure, reward
-
norepinepherine works on
alterness
-
serotonin works on
obsessions and compulsions
-
dopanine, norepinepherine and serotonin together effect
mood
-
norepinepherine and serotonin together affect
anxiety
-
Pysch drug classifications (5)
- antianxiety and hypnotic drugs
- antidepressants
- mood stabilizers
- anticonvulsants
- antipsychotic drugs
-
antianxiety (axiolytics) and hypnotic drug ex's (5)
- bensodiazepines
- short acting sedative hypnotics
- melatonin receptor agonists
- burspirone
- antidepressants
-
antidepressant ex's (6)
- tricyclic antidepressants
- selective serotonin reuptake
- serotonin - norepinephrine reuptake inhibitors
- serotonin - norepinephrine disinhibitors
- monoamine oxidase inhibitors
- other antidepressants
-
what diet to be on when on MAOI's
tiramine free
-
mood stabilizer and anticonvulsant ex's (7)
- lithium
- valproate
- carbamazepine
- lamotrigine
- gabapentin
- topiramate
- oxcarbazepine
-
when taking lithium you must?
monitor closely because of low lethal dose
-
when taking mood stabilizers and anticonvulsants monitor?
can cause?
amount in blood levels, CBC, and liver enzymes
agranulocytosis
-
antipsychotics ex's
- conventional - old block dopamine
- atypical - effects are positive and negative - cause less of the Parkinson's looking SE and EPS
-
other psychoparmacological drugs to consider (3)
- ADHD
- alzhiemer's disease
- herbal treatments
-
effects:
fine muscle movements
integration of emotions and thoughts
involved with decision making
stimulants hypothalamus to release hormones (sex, thyroid, adrenals)
dopamine
-
a decreases in dopamine causes
an increase causes?
Parkinson's disease and depression
schizoprenia and mania
-
effects mood, stimulates sympathetic branch of ANS for "fight or flight"
norepinephrine (NE)
-
a decrease in norepinephrine causes?
an increase causes?
depression
mania, anxiety states, schizophrenia
-
effects sleep regulation, hunger, mood states and pain perception and plays a role in aggression and sexual behavior
serotonin
-
a decrease in serotonin causes?
an increase?
depression
anxiety states
-
plays a role in inhibition, reduces aggression, exitation and anxiety; may play a role in pain perception; effects anticonvulsant and muscle-relaxing properties
GABA
-
a decrease in GABA causes?
an increase?
anxiety disorders, schizophrenia, huntington's chorea
reduction of anxiety
-
plays a role in learning, memory; mood regulation, manic and sexual agression; stimulates parasympathetic nervous system
acetylcholine
-
a decrease in acetylcholine causes
an increase causes
alzheimer's disease, huntington's chorea, parkinson's disease
depression
-
effects alertness, inflammatory response, stimulates gastric secretion
histamine
-
decrease in histamine causes
depression
-
dopamine blockage can cause
movement defects such as - parkinsonian sx, akinesia, akathasia, tardive dyskinesia
increased prolactin - gynecomastia in men and glactorrhea-amenorrhea in women
-
mscarinic blockage causes?
blurred visoin, dry mouth, constipation, urinary difficulty
-
alpha antagonism causes?
orthostatic hypotension and failure to ejaculate
-
examples of atypical antipsychotic drugs
- clozapine (clozaril)
- resperidone (risperdal)
- quetiapine (seroquell)
- olanzapine (zyprexa)
-
few or no EPS sx and target the negative as well as the positive sx or schizoprenia; no motor side effects
atypical antipsychotics
-
adverse effects of lithium:
nervous system and muscle
digestive
cardiac
F&E
endocrine
- tremor, ataxia, confusion, convulsions
- N/V/D
- arrhythimias
- polyuria, polydipsia, edema
- goiter and hyperthyroidism
-
antiepileptic drugs
- carbamazepine (tegretol)
- valproic acid/valproate (depakote)
- clonazepam (klonopin)
-
negative side effects of clozapine
most dangerous
most common
monitor?
- possibly fatal in 1-2% of pts b/c of potential to suppress bone marrow and induce agranulocytosis
- potential for inducing convulsions in 3% of clients
drowsiness, sedation, hypersalivation, tachycardia, and dizziness
WBC's weekly
-
negative side effects of risperidone
motor difficulties, orthostatic hypotension, sedation
-
negative side effects of quetiapine
sedation and weight gain
-
negative SE with valproic acid
what test to monitor?
hepatic failure, birth defects
liver function tests
-
typical/standard antidepressants - tricyclic antidepressants
- amitriptyline (elavil)
- imipramine (tofranil
- nortriptyline (pamelor)
-
negative side effects from TCA's
blurred vision, dry mouth, tachycardia, constipation, sedation and drowsiness
-
examples of selective serotonin reuptake inhibitors (SSRI's)
- fluoxetine (prozac)
- sertraline (zoloft)
- paroxetine (paxil)
- citalopram (celexa)
-
MAOI's
- Phenelzine (nardil)
- tranylcypromine (parnate)
-
foods containing tyramine
aged cheeses, pickled or smoked fish and wine
-
atypical/novel antidepressants examples
- trazodone (desyrel)
- nefazodone (serzone)
- venlafaxine (effexor)
- mirtazapine (remeron)
- bupropion (wellbutrin)
-
negative side effects of atypical/novel antidepresants
- trazodone - orthostatic hypotension, priapism in males (painful continuous erectile state unrelated to sexual desires or activity)
- venlafaxine - heightened anxiety, N/V and dizziness, abnormal ejaculation and impotence in males
- mirtazapine - sedation, weight gain, dry mouth and constipation; antimuscarinic effects are not as strong with this
- bupropion - headache, insomnia, nausea and restlessness and rarely causes sedation, weight gain, or sexual dysfunction
-
antianxiety/anxiolytic drugs
- benzodiazepines
- buspirone (buspar)
-
Benzodiazepines
- diazepam (valium);
- clonazepam (klonopin);
- alparazolam (xanax);
- flurazepam (dalmane);
- triazolam (halcion);
- lorazepam (ativan)
-
side effects of benzodiazepines
- flurazepam and triazolam - hypnotic (sleep inducing) effect
- lorazepam and prazolam - not soporific (sleep producing)
-
drugs that treat ADHD
- methylphenidate (ritalin)
- amphetamines (adderall)
-
negative side effects with ADHD treatment
agitation, exacerbation of psychotic thought processes, hypertension, long-term growth suppression and potential for abuse
-
drugs to treat alzheimer's disease
- tacrine (cognex)
- donepezil (aricept)
-
negative side effects of alzheimer's tx
- tacrine - nausea, abdominal distress, tachycardia and hepatic toxicity
- donepezil - nausea, diarrhea and sedation
-
voluntary admission
sought by the client or client's guardian trhough a written application to the facility
-
____________clients have the right to demand and obtain release
voluntary
-
voluntary admission clients may be required to sign a relase to the staff who re-evaluate the client's condition for possible conversion to ?
involuntary status
-
involuntary admission
made without the client's consent
-
involuntary admission is necessary when?
the person is a danger to themselves or others, is in need of psychiatric treatment, or is unable to meet their own basic needs.
-
necessary for involuntary admission
specified number of physicians must certify that a person's mental health status justifies detention and treatment.
-
three different commitment procedures
judicial determination, administrative determination, and agency determination
-
emergency involuntary hospitalization
who authorizes this?
1-10 days on avg; to prevent dangerous behavior that is likely to harm self or others.
police officers, physicians, and MHP my be disignated by statute to authorize this.
-
observational or temporary involuntary hospitalization
purpose?
who requests this?
required for this type of admission
civil commitment for observational or temporary involuntary hospitalization is of longer duration than emergency hospitalization.
observatio, diagnosis, and treatment of persons who suffer from mental illness or pose a danger to themselves or others.
guardian, family member, physician or other public health officer
medical certification by two or more physicians that a person is mentally ill and in need of treatment
-
long-term or formal commitment
requirements
if the state does not require a judicial hearing before commitment they often provide?
length
extened care and treatment of the mentally ill
solely through judicial or administrative action or medical certification
a judicial review after commitment procedures
generally 60-180 days; may be for an indeterminate period
-
clients who are involuntarily committed do not lose their right of
informed consent
-
conditional release
requires outpatient treatment for a specified period to determine the client's compliance with med protocols, ability to meet basic needs and ability to reintegrate into the community
-
an involuntary client who is conditionally released may be
re-institutionalized withle the commitment is still in effect without recommencement of formal admission procedures
-
discharge - unconditional release
termination of a client-institution relationship; may be court ordered or administratively ordered by the institution's officials
-
clients must be considered legally competent until
they have been declared incompetent through a legal proceeding
-
a voluntary client who is conditionally released cannot be re-institutionalized without
consent unless the institution complies with the procedures for involuntary hospitalization
-
who has discretionto discharge clients
administrative officer of an institution
-
release from the hospital depends on
client's admission status
-
social worker
qualifications
assist the client to prepare a support system that will promote mental health on discharge; including contact with day tx, employers, sources of finacial aid and landlords
licensed and repared in individual, family and group therapies, often as PCP's
-
counselor
prepared in disciplines such as psychology, rehab counseling, and addiction counseling, may augment the tx plan by co-leading groups, providing basic supportive counseling or assisting in psychoeducational and recreational activities
-
psychologists
according to their amster's or doctoral degree prep, they conduct psychological testing, porvide consultation for the team, and offer direct services such as specialized individual, family or marital therapies
-
occupational, recreational, art, music and dance therapists
on the basis , of their specialist preparations they assist the clients to gain skills that help them cope more effectively, to gain or retain employment, to use leisure time to the benefit of their mental health, and to express themselves in healthy ways
-
psychiatrist
employed where?
may provide in-depth psychotherapy or medication therapy or head a team of mental health providersfunctioning as a private service based in the community.
as physicians they may be employed by the hospital or may hold practice privileges in the facility
-
medical physicians
provide on a consultation basis, medical diagnosis and tx. occasionally, prepared as an addictionologist may served in a more direct role on the unit that offers tx for addictive disease
-
mental health workers
like nursing assistants they function under the direction and supervision of RN's. provide assistance to clients in meeting basic needs anbd also help the community to remain supportive, safe and healthy
-
pharmacist
offers a valuable safeguard. physicians and nurses collaborate with them regarding new meds, wihch are proliferating at a steady rate
-
interventions made by the psychiatirc mental health nurse - basic level
- case management
- counseling
- health promotion and health maintenance
- milieu therapy
- psychobiological intervention
- self-care activities
- promotion of self care activities
-
in an inpatient and outpatient setting the Psych mental health nurse (basic level) will:
- coordinate health and human services
- design and evaluate the use of culturally appropriate services
-
the psych mental health nurse (basic level) will use what types of skills
communication, interviewing, problem-solving, crisis intervention, stress management, assertiveness training, and behavior modification
-
some examples of skills a psych nurse (basic level) should have are:
- coduct health assessments
- target at risk situations
- initial interventions (assertiveness training, stress mgt, parenting classes, health teaching)
- use of internet for communication and teaching pruposes with client and family
- targets potential complications related to symptoms or treatment
-
psych mental health nurse (basic level) should know formal and informal info regarding:
coping, interpersonal relationships, mental health problems, mental disorders, tx and their effects on ADL's, developmental needs, and more; information is given in gender developmental, cultural, and educational appropriate levels
-
the psych mental health nurse should provide a therapeutic environment by:
focusing on a wide range of factors such as physical environment, social structures, interactions, and cultural setting
-
psych mental health nurse should administer and monitor responses to:
medications as well as emergency procedures, relaxation techniques, nutrition, and diet regulations, exercise and rest schedules and other somatic treatment
-
the advance level psych nurse should possess all the abilities of a basic level psych nurse in addition to:
- consultation
- prescription authority and tx
- psychotherapy
-
the advanced level psych nurse should encourage highest level of independent functioning in areas such as:
personal hygiene, feeding, recreational activities, practical skills (shopping, using public transportation)
-
the advanced practice nurse should provide consultation to:
health care providers and others as well as supervisino to other mental health care providers and trainers
-
the advanced practice psych nurse may prescribe meds and ?
order and interpret labs
-
the advanced practiced nurse performs?
individual, group, family, child and adolescent psychotherapy
-
uses complimentary therapies, performs clinical supervisory activities, and has an expanded advocacy role
advanced practice psych nurse
-
possible community mental health practice sites
- community mental health centers
- youth centers
- private practice offices
- crisis centers
- shelters (homeless, battered women, adolescent)
- correction facilities, local jails, courts
- primary care offices
- chemical dependency program offices
- client's home
- schools and day care centers
- nrusing homes
- day hospital facilities
- group homes and adult foster homes or day care centers
- work release housing
- industry and business
- ER depts of community hospitals
- outreach to multiple locations, including restaurants, shopping malls
- chruches, temples, synagogues, mosques
- ethnic cultural centers
- hospices and AIDS supportiving living programs
- client's worksite
-
accultruation
nurse must revisit beliefs that there is a single definition of health or that professionals can or should control client behavior
-
community psychiatric mental health nurse attributes
- awareness of self; personal and cultural values
- nonjudgmental
- flexible
- problem-solving skills
- ability to cross service systems (schools, corrections, shelters, HCP, employers)
- knowledge of community resources
- excellent psychosocial and health assessment skills
- excellent communications skills
- knowledge of psychoparmacology
- ability to recognize need for consultation
- calm external manner
- ability to see strength and ability in severly ill
- willingness to work with the family or significant others identfied by the client as support people
- understanding of the social, cultural and political issues that affect mental health and illness
- knowledge of political activism
-
multidisciplinary tx team list
- client
- peer counselors
- family members
- employers
- landlord
- spiritual counselor
- case manager
- chemical dependency counselor
- psychiatric nurse
- psychiatric nurse practitioner
- psychiatrist
- psychiatric social worker
- psychologist
- occupational terapist
- chiropractor
- voc rehab therapist
- nutitionist
- PCP
- recreation therapist
- PT
-
community resources for mental health
- community mental health centers
- homeless shelters
- mobile mental health care units
- forensic setting
- private practice setting
- outpatient chem dependency facilities
- home psychiatric mental helath care
-
ethnocentrism
the assumption that one's own beliefs and practices are the best, preferred, or only way of being
-
explanatory models
documents the kinds of factors or events that people understand to cause distress
-
idioms of distress
forms of experience and expression that distress takes - understood only in their cultural context
-
DSM-IV-TR cultural foundation of psychiatric dx
cultural formulation:
1. cutlural identity
2. cultural explanation of illness
3. cultural factors related to psychosocial environment and levels of functioning
- 1. cultural reference group, language, involvement i culture of origin, involvement in host culture
- 2. predominant idioms of distress, meaning and severity of sx in relation to cultural norms, perceived causes and explanatory models, help-seeking experiences and plans
- 3. social stressors, social supports, levels of functioning and disability
-
cultural ideology or world view
beliefs and values held by people withing a given culture about what is good, right and normal
-
rationale for sample assessment questions r/t beliefs and values
1. what does someone in your community (culture, religion) call this illness?
2. what do people believe caused this illness?
3. do people shun or avoid someone who has this illness?
4. what does a mature person act like - how do they conduct themselves?
- 1. recognize self as cultural being
- 2. recognize practice as based in western beliefs and practices
- 3. collaborate with cultural translator to assess explanatory models
- 4. determine meaning of illness to person and family/ community
-
rationale for sample assessment questions r/t political/economic:
1. what are the social classes, ethnic or racial categories used by the people?
2. how odes being a woman or a man affect someone with this illness?
3. who makes decisions about what needs to be done for the ill person?
4. source and availability of income
5. familiarity with technology
6 accessibility of preferred type of health care and of dominant health care
7. language spoken. language of dominant health care. language barriers to access to health care
8. transportation and infrastructure
- 1-3 match translator with region, ethnicity, social class, and gender whenever possible
- - combat and eliminate racism and oppression
- 4-7 remove environmental aspects that cause illness
- 8. minimize language and environmental barriers
-
rationale for sample assessment questions r/t practice
1. how do people communicate with each other (space, gestures, mannerisms, voice tone)?
2. what is done for the sick, and by whome
3. what dietary practices or restrictions are used when one has this illness
4. are there any ceremonies, special prayers, or other protections used to treat this illness, or protect people from it? who performs these? have they been seen? result?
- 1. assess idioms of distress and their meanings and expression
- 2. determine preferred or commonly used healing methods
- 3. determine caregiver strategies and roles: work with appt members of family
- 4. community based health promotion
-
factors that healing systems have in common
- 1. healing integrates the physical sx with the symbolic system of the culture
- 2. the explanatory models of the client and the healer are congruent
- 3. the healer has characteristics of charisma and confidence
- 4. both the healer and the client conceptualize the illness in cultrual terms
- 5. there are elements of confession or moral witnessing especially in an emotianlly charged or cathartic way
- 6. there is emotional arousal and faith in the healing method both within the client and within the community
- 7. the healer, the family and the community use social persuasion
- 8. healing techniques are rhetorical devices such as irony and paradox.
-
culturally competent clinical services include
- bicultural staffing
- coverage for all encountered languages
- family involvement
- cultural formulation included in assessment
- use cultural interpreters, designated fmaily members, and community liasion work
- biological response to meds
- stigma related to psychiatric dx
- community linkages with predominant non-western and non-white american populations
- get your primary materials translated
- relevant symbols
-
aspects of the patients bill of rights
- civil rights
- client consent
- communication
- freedom from harm
- dignity and respect
- confidentiality
- participation in their plan of care
-
client's rights under the law
- right to treatment
- right to refuse treatment
- right to informed consent
- rights regarding seclusion and restraint
-
civil rights to be maintained
- right to vote
- right civil service ranking
- rights related to granting, forfeit, or denial of license
- right to make purchases and to enter contractual relationsips (unless the client has lost legal capacity)
- right to humane care and tx
- right to religious freedom and practice
- right to socially interact
- right to exercise and recreational opportunities
-
aspects of client consent:
must have proper orders and client consent for certain tx such as
must be documented where?
surgery, ECT, use of experimental drugs or procedures
in the chart
-
communication rights
right to communicate fully and privately with those outside the facility; have visitors; reasonable access to phones, mail and send and receive unopened correspondence; may seek other opinions (at their own expense); will not be forced to work for the hospital; explain rules and regs to clients
-
freedom from harm
unnecessary or excessive physical restraint, isolation, medication, abuse, or neglect - use of meds for punishment is prohibited
-
dignity and respect
legally protected right to be free from discrimination on the basis of ethnic origin, gender, age, disability, or religion
-
confidentiality
records, no photo's without consent; only discuss client with those who have a right to know; discussing client in public is prohibited and they must give consent to discuss person who are not directly involved with their care
-
participation in their plan of care
review written care plan regularly; involve client in decisions; entitled to a discharge plan that includes follow-up care; tx should provide the lease restrictive environment possible; inform client of med SE
-
assault
threat of harm or putting a person in a state of apprehension
-
battery
actual contact with the person
-
tx must meet this criteria
- environment must be humane
- staff must be qualified and sufficient to provide adequate tx
- plan of care must be individualized
-
behavioral restraint and seclusion are authorized as an intervention when:
- the behavior is physically harming the client or third party
- disruptive behavior presents a danger to the facility
- alternative or less restrictive measures are insufficient in protecting the client or others from harm
- when a decrease in sensory overstimulation (seclusion only) is needed
- the client anticipates that a controlled environment would be helpful and requests seclusion
-
the use of seclusion and restraint is permitted only:
- on the written order of a physician
- when orders are confined to specific time-limited periods (every 2-4 hrs)
- when the lcient's condition is reviewed and documented correctly (every 15 min)
- when the original order is extended after review and reauthorization (every 24 hrs) and specifies the type of restraint
-
contraindications to seclusion and restraints
- extremely unstable medical and psychiatric conditions
- delirious or demented patients unable to tolerate decreased stimulation
- overly suicidal patients
- patients with severe drug reactions or overdoses or those patients requireing close monitoring of drug dosages
- (all above unless close supervision and direct observation is provided)
- punishment or convenience of staff
-
common liability issues
- protecting clients
- defamation of character
- supervisory liability
- short-staffing issues
-
protecting clients (example)
not leaving a suicidal pt alone with items to harm themself; medication errors; sexual misconduct
-
defamation of character
either written or oral can be brought if confidential info regarding clients is divulged that harms their reputation
-
supervisory liability
may be incurred if nursing duties are delegated to persons who cannot safely perform these duties.
-
guidlines to avoiding liability:
- always put client's rights and wefare first
- observe the hospital's policy manual
- practice withing scope of nurse practice act
- maintain current understanding of established practice standards
- keep accurate concise and timely nursing records
-
do's of charting
- chart in a timely manner - all factual info
- be familiar with company policy
- chart legibly in ink
- facts fully, descriptively, and accurately
- what you see hear feel and smell
- total pt assessment on admission, discharge and transfer and in between when pertinent
- psychosocial observations, physical sx; behavior
- follow-up care
- fully the facts surrounding unusual occurances or incidents (do not indicate an incident report was filed)
- all nursing interventions, tx, and outocmes
- expressed subjective feelings
- each time you notify MD
- MD visits and tx
- discharge meds and instructions given and teaching
-
don'ts of charting
- opinions not supported by fact
- defame client by calling names or making derrogatory statements
- before an event occurs
- generalizations, suppositions or pat phrases (client in good spirits)
- obliterate, earse, alter, or destroy a record
- leave blank spaces for chronological notes ("late entry")
-
intentional torts
- assault
- battery
- false imprisonment
-
unintentional torts
- negligence
- malpractice
- duty
- breach of duty
- cause in fact
- proximate cause
- damages
-
nursing process in psych mental health nursing
- 1. assessment
- 2. nursing dx
- 3. outcome identification
- 4. planning
- 5. implementation
- 6. evaluation
-
considerations regarding the psychiatric nursing assessment
1. primary
2. secondary
3. tertiary
- 1. preventative, fostering mental health
- 2. treating illness
- 3. rehabilitative
-
assessment should include
- MSE
- construction of database - observation, interviews, hx taking physical exam, standardized rating scales
- verify data
-
Nursing dx should include
- identify problem and etiology
- make nursing dx and problem list
- prioritize nursing dx
-
outcome identification
set goals
-
planning
plan nursing care
-
care plan implementation:
basic level intervention
advanced practice
counseling, millieu, self-care, psychological intervention, case mgt, health promotion and maintenance, health teaching
psychotherapy, prescription of meds, consultation
-
outcom evaluation
- outcome/goals have/have not been met
- additional data gathering, reassessement, revise plane
-
standards of professional performance
- quality of care
- performance appraisal
- CE
- collegiality
- ethics of care
- interdisciplinary collaboration
- research
- use of community health systems
- resource utilization
-
when establishing a rapport consider
- personal considerations
- age considerations
- developmental stages, child/adult/geriatric, observe children playing
-
components of an MSE
personal info, appearance, behavior, speech, affect and mood, thought process, perceptual disturbances, cognition, insight, judgment
-
outcome criteria should be
realistic, achievable, measurable, NOC, grounded in clinical practice and research, standardized
-
planning (interventions) should be
NIC, safe, appropriate, individualized, EBP, match defining data
-
bower's basic nursing action
- right to decide own destinies and be involved in decisions
- help individuals meet their own needs or to solve their own probs
- assist individuals in maximizing their independent level of funtioning
-
nontherapeutic relationship with client
- social - friendship/ no structure or set boundaries
- initmate - sexual
-
goals in a therapeutic relationship
- facilitating - communication of distressing thoughts and feeelings
- assisting - client with problem solving to help ADL's
- helping - examine self-defeating behaviors and test alternatives
- promoting - self-care and independence
-
therapeutic relationship
focuses on
the nruse maximizing inner commuication skills, understanding of human behaviors and personal strengths to enhance the client's growth
client's ideas, experiences and feelings, personal issues - CLIENT'S NEEDS ONLY
-
factors that enhance growth in others
- genuineness
- empathy
- positive regard
-
beneficial behaviors of nurse-client relationship
- consistency
- pacing
- listening
- initial impression
- comfort and control
- client factors
-
hampered behaviors of nurse-client relationship
- inconsistency
- unavailability
- lack of self-awareness
- negative feelings
- inconsiderate of client's needs
-
goals of nurse are to help the client:
- identify and explore problems relating to tohers
- discover healthy ways of meeting emotional needs
- experience satisfying interpersonal relationships
- feel understood and comfortable
-
in communicating therapeutically the nurse should:
- ask open ended questions (some closed may be necessary)
- use clarifying techniques - paraphrasing, restating, reflecting, exploring (tell me more aobut...)
- use of silence
- active listening
-
no therapeutic communication consist of:
- asking excessive questions
- giving approval/disapproval
- advising
- why questions
- premature advice
- minimize client feelings
- false reassurance
- nonverbal signs of boredome
- value judgments
- change subject
-
common defense mechanisms
- repression
- denial
- projection
- reaction-formation
- regression
- rationalization
- identification
- introjection
- displacement
- sublimation
-
freud's psychosexual stages of development
- oral (0-1y/o)
- anal (1-3 y/o)
- phallic (3-6 y/o)
- latency (6-12 y/o)
- genital (12 yrs and older)
-
erikson's eight stages of development
- trust vs mistrust (0-1 1/2 yrs)
- autonomy vs shame and doubt (1 1/2 - 3 yrs)
- initiative vs guilt (3-6 yrs)
- industry vs inferiority (6-12 yrs)
- identity vs role confusion (12-20 yrs)
- intimacy vs isolation (20-35)
- generativity vs self - absorption (35-65)
- integrity vs despair (65- death)
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