Week 1 Mental Health ATI PDF

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Chapter 1: Basic Mental Health Nursing Concepts Psychosocial history i. Assess the client’s perception of own health, beliefs about illness and wellness. Mental Status Examination (MSE) i. Lethargic- client is able to open their eyes and respond but is drowsy and falls asleep readily ii. Stuporous- client required vigorous or painful stimuli to elicit response. Client may not be able to respond verbally iii. Comatose- unconscious and does not respond to painful stimuli a. Decorticate rigidity- flexion and internal rotation of upper-extremity joints and legs b. Decerebrate rigidity- neck and elbow extension, wrist, and finger flexion Behavior i. Affect: a client’s affect is an OBJECTIVE expression of mood Cognitive i. Immediate: ask the client to repeat a series of numbers or list of objects ii. Recent: ask the client to recall recent events (visitors from the current day) or the purpose of the current mental health appointment or admission iii. Remote: ask the client to state a fact from their past that is verifiable (their birth date or mother’s maiden name) Mini- mental state examination (MMSE) i. This examination is used to objectively assess a client’s cognitive status by evaluating: a. Orientation to time and place b. Attention span and ability to calculate by counting backward by seven c. Registration and recalling of objects d. Language, including naming of objects, following commands, and ability to write Considerations across lifespan: children and adolescents i. The client should be the source of the information but with children and adolescents, caregivers can also provide valuable information ii. Use the HEADSSS standardized assessment tool: i. Home environment: what is the clients relationship like with their guardian and other family members living in the home? ii. Education/Employment: is the client employed? How is the client’s school performance? iii. Activities: Does the client participate in sports or other activities? How does the client interact with peers? iv. Drugs and substance use: Does the client use substances? v. Sexuality: Has the client engaged in any sexual activity or had any sexual encounters? vi. Suicide/ Depression: is the client at risk for suicide or self-injury? Does the client have indications of depression?

Safety: is the client exposed to abuse in the home or violence in the neighborhood? Considerations across the lifespan: older adults i. Geriatric depression scale (short form) ii. Stand or sit at the client’s level Milieu therapy i. Orienting client to physical setting ii. Identifying rules and boundaries of the setting iii. Ensuring a safe environment for the client iv. Assisting the client to participate in appropriate activities vii.

Chapter 2: Legal and Ethical Issues Legal Rights of clients in the mental health setting i. Some legal issues regarding health care are decided in court using a specialized civil category called a tort. a. a tort is a wrongful act or injury committed by an entity or person against another person or another person’s property. Ethical issues for clients in the mental health setting i. Beneficence- the quality of doing good; can be described as charity ii. Autonomy- the clients right to make their own decisions. iii. Justice- fair and equal treatment for all iv. Fidelity- loyalty and faithfulness to a client v. Veracity- honesty Confidentiality i. HIPPAA ii. Specific mental health issues where health care professionals can break confidentiality include the duty to warn and protect third parties, and the reporting of child and vulnerable adult abuse. Types of Admission to a mental health facility i. Informal admission- the client does not pose a substantial threat to themselves or others. The client is free to leave the hospital at any time. ii. Voluntary admission- the client or client’s guardian chooses admission to a mental health facility in order to obtain treatment. This client is considered competent and has the right to refuse medication and treatment. Before release, the client must be evaluated prior to discharge. iii. Temporary emergency admission- the client is admitted for emergent mental health care due to the inability to make decisions regarding care. The length of the temporary admission should not exceed 15 days. iv. Involuntary admission: the client enters the mental health facility against their will for an indefinite period of time. The admission is based on the client’s needs for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care. Limited to 60 days. a. Criteria:

i. Presence of mental illness ii. Poses a danger to self of others iii. Demonstrated severe disability or inability to meet basic necessities. b. The number of physicians required to certify that the clients condition requires commitment is usually two. c. Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, including medication. d. The client who has been judged incompetent has a temporary or permanent guardian appointed by the court. v. Long term involuntary admission: A type of admission that is similar to temporary commitment but must be imposed by the courts. Usually, 60-180 days but sometimes has no release date. Client rights regarding seclusion and restraint i. Restraints are either physical or chemical ii. A client can voluntarily request temporary timeout in cases in which the environment is disturbing or seems too stimulating. iii. The provider should prescribe seclusion and/or restraint for the shortest duration necessary, and only if less restrictive measures are not sufficient. They are only for physical protection of the client and staff. iv. Less restrictive measures: a. Verbal interventions (encouraging client to calm down) b. Diversion/ redirection c. Provide calm environment d. Offer PRN medication v. The provider must prescribe the seclusion or restraint in writing. a. Time limits: i. 18 or older: 4 hr ii. 9-17: 2 hr iii. 8 or younger: 1 hr b. If needed longer, provider must reassess and rewrite prescription. vi. Complete documentation every 15 to 30 mins vii. The nurse can use seclusion in emergency situations. Need written prescription within 15-30 min. Intentional torts i. Willful actions that damage a client’s property or violate client’s rights. ii. False imprisonment: confining a client to a specific area OR using chemical restraint when it is not a part of the client’s treatment. iii. Assault: making a threat iv. Battery: doing the threat Unintentional torts i. Negligence: failing to provide adequate care in a personal or professional situation when one has an obligation to do so. ii. Malpractice: a type of professional negligence Documentation

i. Client behavior: in a clear and objective manner ii. Staff response: to disruptive, violent, or potentially harmful behavior. iii. Time the nurse notified the provider: and any prescriptions received. Chapter 3: Effective Communication Verbal communication: i. Denotative/ connotative meaning: words that have multiple meanings ii. Timing/ relevance: communicating while client is in pain is bad iii. Pacing: speaking rapidly can tell the client that the nurse is in a rush and does not have time for client iv. Intonation: tone of voice Assessment: adolescents i. the adolescent at risk for refusal of treatment due to a desire to be “normal”? Assessment: older adult clients i. Recognize that the client may require amplifications ii. Minimize distractions, face client when speaking. iii. Allow plenty of time for the client to respond Effective communication skills and techniques iv. Silence: allows for meaningful reflection v. Active listening vi. Questions: o Open-ended questions: facilitates spontaneous responses and interactive discussion o Closed-ended questions: helpful if used sparingly during initial interaction o Projective questions: “what if” o Presupposition questions: explores the client’s life goals or motivations o Clarifying techniques  Reflecting  Restating  Paraphrasing  Exploring vii. Presenting reality: helps client focus on what is actually happening and to dispel delusions, hallucinations, or faulty beliefs. Barriers to effective communication: i. Asking irrelevant personal questions ii. Offering personal opinions iii. Giving advice iv. False reassurance v. Minimizing feelings vi. Changing topic vii. “why” questions viii. Giving approval or disapproval

Chapter 5: Creating and Maintaining a therapeutic and safe environment Milieu Therapy i. Milieu therapy creates an environment that is supportive, therapeutic, and safe. ii. Management of the total environment of the mental health unit in order to provide the least amount of stress iii. The goal is that while the client is in this therapeutic environment, the client will learn the tools necessary to cope adaptively, interact more effectively and appropriately, and strengthen relationship skills. Roles of the nurse i. Identify and explore the client’s needs and problems. Characteristics of the therapeutic milieu ii. Allow choices for clients within the daily routine and within individual treatment plans Benefits of the therapeutic relationship nurse factors: iii. Consistent approach iv. Positive initial impressions Boundaries of the therapeutic relationship i. Social relationship: purpose is socialization and friendship with mutual needs of the individuals ii. Therapeutic relationship: primary purpose is to identify the clients problems or needs and then focus on assisting the client in meeting or resolving these issues. iii. Transference: when the client thinks the nurse reminds them of someone significant to their life iv. Countertransference: the nurse thinks the client reminds them of someone significant to their life Physical safety i. Set up the following provisions to prevent client self-harm or harm by others. a. No access to sharps b. Restriction of client access c. Monitoring visitors d. No alcohol/ illegal substance use e. No sexual activity between clients f. No elopement g. Rapid de-escalation of disruptive behavior ii. Seclusion rooms and restraints only to be used after all less-restrictive measures have been exhausted. Activities within the therapeutic milieu

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Community meetings: enhance emotional climate of the therapeutic milieu by promoting: a. Interaction/communication between clients and staff b. Decision making skills of clients c. Self-worth among clients d. Discussion of common objectives e. Discussion of issues to concern all members of the unit f. Client-led Individual therapy: schedules sessions with mental health provider Group therapy: scheduled sessions for a group of clients with common mental health concerns Psychoeducational groups: based on clients level of functioning and personal needs (adverse effects of medications) Recreational activities: games and community outings Unstructured, flexible time: nurse and staff to observe clients as they interact spontaneously within milieu

Phases and tasks of therapeutic relationships i. Orientation a. Introduction, set contract, discuss confidentiality, build trust by establishing boundaries, set goals, explore clients ideas issues and needs, explore meaning of testing behaviors. ii. Working a. Maintain relationship per contract, ongoing assessment to plan and evaluate therapeutic measures, facilitate clients expression of needs and issues, encourage client to problem solve, promote clients self-esteem, foster positive behavioral change, explore and deal w resistance, recognize transference and countertransference, reassess, remind client about date of termination iii. Termination a. Provide opportunity for client to discuss thoughts and feelings about termination and loss, discuss clients previous experience with separations and loss, elicit clients feelings about therapeutic work in the relationship, summarize goals and achievements, review memories of work, express own feelings about session, discuss healthy ways to incorporate new healthy behaviors into life, maintain limits of final termination Chapter 6: Diverse Practice Settings Acute Care i. This setting provides intensive treatment and supervision in locked units for clients who have severe mental illness, who present dancer to self or to others. a. Care helps stabilize mental illness manifestations and promotes the clients rapid return to the community

b. Facilities might be privately owned or general hospitals, with payment provided by private funds or insurance. c. State-run facilities also often provide full-time acute care for forensic clients (those in a correctional setting) who have severe mental illness d. Case management programs assist with client transition to a community setting after discharge from the acute care facility. Community ii. Primary care is provided in community-based settings, which include clinics, schools, and day-care centers, partial hospitalization programs, substance treatment facilities, forensic settings, psychosocial rehab programs, telephone crisis counseling centers, and home health care. a. Nurses help to stabilize client’s mental functioning within a community. Forensic Nursing iii. A combo of biophysical education and forensic science. iv. The RN uses scientific investigation, collection of evidence, analysis, prevention, and treatment of trauma and/or death of perpetrators and victims of violence, abuse, and traumatic accidents. History of mental health care in the United States i. Most clients who have severe mental illness were treated solely in acute care. ii. The concept of case management was introduced around 1970 iii. Managed Behavioral Healthcare Organizations (MBHOs) later developed to coordinate care and limit stays in acute care facilities for clients needing mental health care. Client Care Acute Mental health care settings i. Criteria to justify admission to an acute care facility include a. Clear risk of clients danger to self or others b. Inability to meet basic needs c. Failure to meet expected outcomes of community-based treatment d. Dangerous decline in mental health status of client undergoing long-term treatment e. Client having medical need as well as mental illness ii. Goals of acute mental health treatment a. Prevention of client harming self or others b. Stabilizing mental health crisis c. Return of clients who are severely ill to some type of community care Community health settings i. Intensive outpatient programs promote community reintegration for clients

Levels of prevention ii. Primary Prevention: teaching iii. Secondary prevention: screening for early detection iv. Tertiary prevention: rehab Community based mental health programs i. Partial hospitalization programs a. Short-term intense treatment for clients who are well enough to go home every night and who have a responsible person at home to provide support and a safe environment ii. Assertive community treatment (ACT) a. Nontraditional case management and treatment by an interprofessional team for clients who have severe mental illness and are noncompliant with traditional treatment. b. Helps reduce recurrences of hospitalizations and provides crisis intervention, assistance with independent living, and information regarding resources for necessary support services. iii. Community mental health centers a. Educational groups b. Medication dispensing programs c. Individual and family counseling program iv. Psychosocial rehabilitation programs a. Residential services b. Day programs for older adults v. Home care a. In the clients home; often for children, older adults, and adults who have medical conditions. With psychiatric home care, there are four criteria that must be met. b. The client must be homebound, have psychiatric diagnoses, need the skills of the mental health nurse and a plan of care developed by the health care provider. QUESTIONS: 1) A nurse is planning care for several clients who are attending community-based mental health programs. Which of the clients should the nurse visit first? a) A client who reports hearing a voice saying that life is not worth living anymore 2) A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention? a) Establishing rehabilitation programs to decrease the effects of depression 3) A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply.) a) Educational groups b) Medication dispensing programs c) Individual counseling programs d) Family therapy

4) A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client’s partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for a follow-up care? a) Attending a partial hospitalization program 5) A nurse is caring for a group of clients. Which of the following clients should a nurse consider for a referral to an assertive community treatment (ACT) group? a) A client who lives at home and keeps “forgetting” to come in for a scheduled monthly antipsychotic injection for schizophrenia

Chapter 7: Psychoanalysis, psychotherapy, and behavioral therapy i.

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Classical psychoanalysis is a therapeutic process of assessing unconscious thoughts and feelings and resolving conflict by talking to a psychoanalyst. a. This can take months to years b. Unlikely to be the sole therapy of choice Transference: includes feelings that the client has developed toward therapist in relation to similar feelings toward significant persons in the clients early childhood. Countertransference, the unconscious feeling that the healthcare worker has toward the client.

Therapeutic tools i. Free association: the spontaneous, uncensored verbalization of whatever comes to a client’s mind ii. Dream analysis and interpretation: the urges and impulses of the unconscious mind that played out through the dreams of clients. Psychotherapy i. Involves more verbal therapist-to-client interaction. ii. Psychodynamic therapy: focuses more on clients present state. Lasts longer iii. Interpersonal psychotherapy (IPT): addressing specific problems a. Goal is to improve interpersonal and social functioning which will reduce psychiatric manifestations iv. Cognitive therapy: focuses on individual thoughts and behaviors to solve current problems. a. Treats depression, anxiety, eating disorders, and other issues that can improve by changing a client’s attitude toward life experiences. v. Behavioral therapy: changing behavior is the key to treating problems. a. Teach clients ways to decrease anxiety or avoidant behavior and give clients an opportunity to practice techniques. Teaches activities to help client reduce anxious and avoidant behavior like relaxation training and modeling.

Cognitive-behavioral therapy i. Takes into account what clients think influences their feelings and behaviors Dialectical behavior therapy ii. Helps pt with personality disorders and exhibits self-injurious behavior. This focuses on gradual behavior changes and provides acceptance and validation for these clients. Use of cognitive therapy Cognitive reframing iii. Identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk. a. Ex: a client who has depressive disorder might say they are a bad person who has never done anything good in their life. Through therapy, this client can change their thinking to realize that they might have made some bad choices, but that they are not a bad person. iv. Priority restructuring: assists clients to identify what requires priority. v. Journal keeping: helps clients write down stressful thoughts and has a positive effect on well-being vi. Assertiveness training: teaches clients to express feelings, and solve problems in a nonaggressive manner. vii. Monitoring thoughts: helps clients to be aware of negative thinking Types and uses of behavioral therapy: i. Modeling a. The...