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MH CONDENSED NOTES WEEK 1 Where do Mental Health Nurses Fit in?  The essence of mental health nursing lies in the quality of the professional relationship developed between the person with a mental health problem and the nurse - the therapeutic relationship  Mental Health Nursing is: o A specialised area of nursing o focuses on working with consumers to meet their recovery goals o MH nurses consider person’s physical, psychological, social & spiritual needs - in the context of persons lived experience o support consumers & their families during crisis and transition periods o liaise with range of health care providers, provide information & education, coordinate care & provide talking therapy  Foundations o The development of meaningful, interpersonal relationships is crucial to mental health nursing. These relationships provide insight into each individual, equipping nurses to interact with consumers in a therapeutic way. The therapeutic relationship/alliance also encourages consumers to be actively engaged with care. o Characteristics of a therapeutic relationship: Professional, mutual, collaborative, goal directed, open, negotiated, committed, sensitive, empathic, genuinely caring, nonjudgemental. o In contemporary practice, consumers are recognised as experts by experience. That is, consumers have a unique perspective and novel insight regarding mental illness, and this should be respected. o It is important to understand what consumers have been through. By understanding the lived experience, we develop insight into what it is like to have a mental illness, and what it is like to receive care for a mental illness. With these insights, we can then augment and enhance the care that we provide. This is a way of developing more effective, better experienced care Recovery  What is recovery o Non-linear journey o Individually determined o Focused on autonomy and self-agency o Involves meaningful roles and employment o Familial and community integration  Recovery is typically defined as: o 'a deeply personal, unique process of changing one’s attitudes, values, feelings, goals, skills and/or roles. It is a way of living a satisfying, hopeful, and contributing life even with limitations caused by the illness. Recovery involves the development of new meaning and purpose in one’s life as one grows beyond the catastrophic effects of mental illness.’  10 Components of Recovery: o Self- direction, Individualised and person centred, Empowerment, Hollistic, Non-linear, Strengths based, Peer support, Respect, Responsibility and Hope.  Personal recovery: CHIME o Connectedness o Hope and optimism o Identity o Meaning o Empowerment

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Recovery Based Language o The language used in mental healthcare o Consumer/client:  The term ‘patient’ carries paternalistic, dependent connotations, which contravene recovery principles. This In Australia the key MH organisations and policy documents use the term ‘consumer’. A good tip is to ask the person what they prefer to be referred to as. o Respectful, non-judgemental and conveying a positive regard, clear and understandable, hopeful for the future o Do not use language that separates the consumer from their humanity (do not use terms such as ‘schizophrenic’ or anorexic’. A better mode of expression is ‘Jill has schizophrenia’)

WEEK 2 Mood disorders   

A group of disorders in which pathological mood – a sustained and pervasive emotional state, affecting psychosocial, physical and occupational functioning – is experienced. The disordered mood is distinct from that which is usually experienced and there is a sense of loss of control over the mood The primary mood disorders are: o Major depressive disorder o Bipolar disorder

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Mood is a pervasive and sustained emotional state, experienced by an individual. It ‘colours’ one’s view of the world, and reciprocally affects behaviour and cognition.

Treatments & Therapies 

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Depression o Pharmacology  Antidepressants – selective serotonin reuptake inhibitors (SSRIs), selective noradrenaline reuptake inhibitors (SNRIs), monoamine oxidase inhibitors (MAOIs), tricyclics.  Improvement in mood can take 3-5 weeks to start o Electroconvulsive therapy (ECT)  When urgent response is needed – if client’s life is threatened in a severe depressive disorder  For a treatment resistant depressive disorder, where symptoms have not responded to medication treatment o Hospitalisation - may be required when illness is not responding to treatment, or if risk of harm is too great. Bipolar Disorder o Pharmacology  Mood stabilisers: Lithium Carbonate, Sodium Valproate  Lithium requires regular blood tests: weekly tests until serum levels stabilise  Antipsychotics: Some antipsychotics have mood stabilising properties and are useful in treating acute mania and depression (aripiprazole, olanzapine, quetiapine….) o Hospitalisation  May be required when illness is not responding to treatment, or if risk of harm is too great Anxiety o Psychoeducation – powerful therapeutic tool in the alleviation of distress caused by anxiety disorders  Teaching people about the function and purpose of anxiety  Education about heightened anxiety & the cycles that develop  Providing Information – self directed learning through websites, handouts, books

Social support – identifying persons current level of social support  Assisting to enhance support from family, friends, wider community  Exploring socioeconomic needs (housing, isolation, poverty…) o Relaxation techniques/diversional therapy  Slow breathing, meditation, visualising, progressive muscle relaxation, exercise o Pharmacology  Not usually used for as a first line in therapy  SSRIs & Benzodiazepines  Atypical antipsychotics: Quetiapine Cognitive Behaviour Therapy (CBT) o Effective evidence based talking therapy o Proposes that our cognitions (day to day thoughts/beliefs) play a major role in affecting our behavioural responses, & our resulting physiological responses, as well as promoting or reinforcing our emotional states o Each factor can perpetuate both distress & dysfunction within the other areas and can create a cycle o CPT interventions are psychotherapeutic approaches addressing problematic emotions, behaviours, and cognitions through a goal-oriented, systematic approach. o

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WEEK 3 What are we as nurses to do? -Screening   

Management Education Referral

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Stages of change

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Precontemplation

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People in this stage are not thinking seriously about changing and tend to defend their current AOD use patterns. May not see their use as a problem. The positives or benefits, of the behaviour outweigh any costs or adverse consequences so they are happy to continue using.

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Contemplation

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People in this stage are able to consider the possibility of quitting or reducing AOD use but feel ambivalent about taking the next step. On the one hand AOD use is enjoyable, exciting and a pleasurable activity. On the other hand, they are starting to experience some adverse consequences (which may include personal, psychological, physical, legal, social or family problems).

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Preparation

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Have usually made a recent attempt to change using behaviour in the last year. Sees the 'cons' of continuing as outweighing the 'pros' and they are less ambivalent about taking the next step. They are usually taking some small steps towards changing behaviour. They believe that change is necessary and that the time for change is imminent. Equally, some people at this stage decide not to do anything about their behaviour.

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Action

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Actively involved in taking steps to change their using behaviour and making great steps towards significant change. Ambivalence is still very likely at this stage. May try several different techniques and are also at greatest risk of relapse.

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Maintenance

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Able to successfully avoid any temptations to return to using behaviour. Have learned to anticipate and handle temptations to use and are able to employ new ways of coping. Can have a temporary slip, but don't tend to see this as failure.

WEEK 4 Risk Assessment ‘Reconceptualising suicide risk assessment: A person-centred approach to needs-based exploration of current suicidality’: Summary 

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Ultimately, accurate prediction of suicide is impossible. This is attributable to a range of factors, such as, but not limited to: o Peoples shame and secrecy around suicidal preoccupations. o Means of detection are not sensitive enough to quickly changing mental states Suicide Risk Assessment is enhanced by: o An effective approach involves a Therapeutic Relationship o Suicide risk management must focus on short term prevention, not just long term prediction. Suicide Risk Assessment o Formal process by health professionals to gauge/estimate a person’s short-term, mediumterm & long-term risk for suicide o Checklists developed & used in MH services & ED – important to remember assessing for suicide risk requires more care & thought than completing a checklist or assessment tool o There is no clinical assessment tool that predicts with totally certainty whether or not a person will attempt suicide - need to make a reasonable decision based on available evidence/information Risk factors o Suicide risk is dynamic and fluctuating (Hawgood & De Leo, 2015). o Risk factors are potential indicators of risk, however, tools that screen for risk factors are not sensitive or specific enough to be reliable in clinical practice. o Assessment must include:  Detailed evaluation of suicidal behaviour & ideation,  Full psychiatric assessment,  Determination of the psychosocial circumstances,  If possible, assessment should include family members. Protective factors o Previous help seeking behaviour o Strong dependable social supports, significant & stable relationships (friends, family, significant others), children under 18 years living at home o Stable employment & accommodation o Prolonged abstinence from substances o Effective coping & problem solving skills, positive values & beliefs, hopefulness o Availability of effective treatment, positive engagement with services, therapeutic alliance evident, awareness of early warning signs, concerns about effect of suicide on others o

Restricted access to lethal means

WEEK 5 Therapeutic Alliance ‘the caring relationship’ 

The therapeutic alliance refers to the relationship between a healthcare professional and patient/consumer, and the way that it contributes to good outcomes.

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The term ‘therapeutic alliance’ or ‘working alliance’ was introduced in recognition of the way that a relationship can influence outcomes of care. The way you interact with consumers, and the relationships you share, make a difference. The Working Alliance (Therapeutic Alliance) has been described as a tripartite concept. That is, the working alliance has three operating features: 1.

A mutual agreement on goals,

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A mutual agreement on the tasks for achieving goals, and,

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An interpersonal bond.

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Why is the Therapeutic/Working Alliance important in Mental Healthcare? o The Goals and Tasks in the medical settings are more readily tacitly agreed upon, whereas in mental healthcare settings there are substantial variations in care and expectations: o Medical care can be impersonal (a course of antibiotics), mental healthcare is the personal.

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Attributes of the therapeutic alliance o Partnership The nurse engages in ongoing negotiation with the consumer towards recovery goals, with sound interpersonal finesse. o Consumer Focus Care is delivered in close consideration of the consumer’s individual strengths, needs and goals. o Consumer Empowerment The process of enabling the consumer to exercise greater agency over their recovery, which may involve the nurse mobilising resources for the consumer. Tenants of therapeutic alliance o Healthcare Culture  Overarching recovery culture  Permitting Staffing routines

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Bi-Lateral Participation -The consumer must be able to participate in the relationship.  The nurse must possess the requisite attitudes and motivation to engage in the therapeutic alliance. o Interpersonal Engagement  Rapport, understanding, a non-judgemental attitude, friendliness, compassion, acceptance, trust, respect, empathy, honesty, warmth and sensitivity. o Self-awareness  Reflection and self-management of thoughts and feelings towards consumers. o Nursing Support and Education  Nurses need adequate support in the clinical setting and opportunities for education. o Equality: the balance between support and autonomy  It is important that consumers are suitably supported by nurses whilst also having the requisite autonomy to be able to achieve individual recovery goals. Outcomes of the alliance o Extensive research demonstrates that the therapeutic alliance can result in:  Greater commitment to therapeutic activities (medication, therapy, etc),  Retention in care (reduced dropout),  An enhanced overall perception of care and  Enhanced well-being and outcomes. o

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Interpersonal Finesse 

Mental Health Nursing o Boundary  Understanding the Power Differential  Self-awareness: Be conscious of how you come across and your motivations  Maintaining a stance of abstinence and neutrality  The tendency towards conservative emotional investment management o Understanding the Power Differential  Understand that you are in a position of authority. The relationships you have with the people under your care are not friendships. A relationship that resembles ‘friendship’ leaves you vulnerable to inefficacy. o Self-awareness: Be conscious of how you come across and your motivations  Your physical appearance will influence the way that consumers interact with you, and your own motivations will influence your interactions with the people under your care.  Maintaining a stance of abstinence and neutrality  You will care for a variety of people with varying personalities and beliefs. Some of whom you will have a strong affinity for, others you might find contemptible. o The Tendency Towards Conservative Emotional Investment 

Whilst over involvement with a patient can be harmful, an interpersonally conservative approach is not appropriate either.

WEEK 6 Anorexia Nervosa: aetiology  

Temperament/psychological factors- Early childhood anxiety traits, OCD/perfectionist traits, ADHD and ASD are mental health issues that increase risk of developing AN. Culture & Environment- It is supposed that Western idealisation of slim body-types has increased risk of AN, as the majority of recorded AN cases occur in postindustrialised nations. People who engage in activities which require slim bodies (such as modelling, dancing and elite athletics) are at a higher risk of eating disorders.

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Genetic Influence- It is becoming increasingly clear that genetics plays a strong role in determining the overall likelihood of developing an eating disorder.

Anorexia Nervosa: manifestations 

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Physical Manifestations: o Physical appearance: Emaciation and lanugo. o Vital signs: Bradycardia, hypothermia and hypotension. o Deranged electrolyte values: low or on the low side of normal. o Endocrine alterations: Low oestrogen and amenorrhoea in women, lower testosterone in men. o Orthopaedic: The combination of low oestrogen, reduced calcium intake and high intensity exercise increases risk of reduced bone density and stress fractures. Psychological Manifestations: o The starvation state is liable to induce OCD like symptoms, depressive symptoms, and diminished libido. These typically correct on weight gain. Behavioural Manifestations: o Extreme weight maintenance behaviours: purging, avoidance of particular foods, intense exercise regimes.

Anorexia Nervosa: treatment  

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Setting: Outpatient or inpatient. Nutritional support: o Outpatient: Dietician referral. o Inpatient: Supervised meals, management of refeeding syndrome, NG feeding, behavioural monitoring (mitigation of weight maintenance behaviours), high fidelity weighing Therapies: o CBT, Maudsley model therapy, o Medications are not known to work for the treatment of AN.

Anorexia Nervosa: prognosis   

50% will fully recover after receiving care, 30% will carry a sub-clinical, 20% will have a chronic course of illness. Of all mental disorders, Anorexia Nervosa has the highest mortality rate. Deaths from AN may be attributed to starvation, electrolyte imbalance or suicide. Recovery from AN involves more than weight restoration, and takes many years. Many people who have recovered from AN report that their recovery involved the adoption of greater meaning and purpose in life.

Bulimia Nervosa: aetiology  

Temperament/psychological factors- Preoccupation with weight, low self-esteem, depressive symptoms, anxiety in childhood are associated with increased risk for the development of BN. Culture & Environment- Internalization of a thin body ideal has been found to increase risk for developing weight concerns, which in turn increase risk for the development of BN. Individuals who experienced childhood sexual or physical abuse are at increased risk for developing BN. Childhood obesity increases risk for BN.

Bulimia Nervosa: manifestations 

Several laboratory abnormalities may occur as a consequence of purging. These include fluid and electrolyte abnormalities, such as hypokalemia (which can provoke cardiac arrhythmias), hypochloremia, and hyponatremia. The loss of gastric acid through vomiting may produce a metabolic

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alkalosis and the frequent induction of diarrhea or dehydration through laxative and diuretic abuse can cause metabolic acidosis. Tooth enamel may be substantially damaged by repeated vomiting. Callouses may appear on knuckles do due repeated contact with teeth (Russell’s sign) Parotidomegaly (hypertrophy of salivary glands) may occur as a consequence of sustained induced vomiting.

Bulimia Nervosa: treatment   

BN does not typically result in life threatening complications, so inpatient care is relatively uncommon. Care is typically delivered on an outpatient basis. Treatment may involve nutritional support and education, and outpatient therapy (CBT). Medications may be used to treat comorbid mental health issues, such as depression and anxiety.

Diabulimia  

Only effects type 1 diabetics, it occurs when someone reduces or stops taking their insulin to lose weight. However, they need insulin to live so there is life threatening consequences. “is addictive as you can eat what you want but not gain weight”

WEEK 7 ELDERLY

Dementia

Delirium

Depression

Prevalence: In 2009 prevalence rates of dementia were 1.1% but this is expected to rise to 3.2% by 2050 of the population. AIHW says that 1.9 % of those aged between 65-74, 8.4% of those aged between 75-84 years and 22.4% of those aged over 85 years have dementia. Onset: Chronic Course: Slow, progressive cognitive loss; symptoms may be worse in the evening (sundowning) Duration: years Signs and Symptoms: (highly dependent on the stage of illness) Conscious; Short-term memory loss but good long term memory; sleep disturbance not a feature but sleep-wake cycle may be set at wrong time frame; Behaviour is worse in the evenings; Aimless wandering or searching; Hallucinations are rare; Mood may be flattened or labile. Prevalence: Delirium is very common in older peop...