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NCLEX-RN PREPARATION PROGRAM MENTAL HEALTH DISORDERS Module 6, Part 1 of 3.

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1 NCLEX-RN PREPARATION PROGRAM MENTAL HEALTH DISORDERS Module 6, Part 1 of 3

2 2 Module Description This module will prepare the graduate nurse to pass the NCLEX exam in the area of mental health. Included in this module is a review of the following areas: Therapeutic communication and milieu therapy Nursing process Mental illnesses and disorders Psychopharmacology Life span development issues

3 3 Introduction The nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client—they are the “tools” of psychosocial intervention.

4 4 What is Communication? Interpersonal communication is a transaction between the sender and the receiver. Both persons participate simultaneously. In the transactional model, both participants perceive each other, listen to each other and simultaneously engage in the process of creating meaning in a relationship.

5 5 Communication Includes: dominant language, dialects, contextual use of language; Paralanguage variations such as voice volume, tone, inflections and willingness to share thoughts and feelings; Nonverbal communications such as eye contact, gesturing and facial expressions, use of touch, body language, spatial distancing practices and acceptable greetings;.

6 6 Communication Communication is: Temporary in terms of past, present and future orientation of worldview; Clock versus social time, and the amount of formality in use of names

7 7 Therapeutic communication techniques encourage the client or other individual with whom the nurse is communicating to express their thoughts and feelings. Communication

8 8 Technique Active Listening Broad Openings Description Carefully noting what the client is saying and observing the client’s nonverbal behavior Encouraging the client to select topics for discussion Communication

9 9 Technique: Clarifying Focusing Description: Making the message clearer, to correct any misunderstanding, and to promote mutual understanding Directing the conversation onto the topic being discussed Communication

10 10 Technique: Informing Open-ended questions Description: Giving information to the client Encourage conversation because questions require more than just one-word answers Communication

11 11 Technique: Paraphrasing Reflecting Silence Description: Restating in different words what the client said Directing the client’s question or statement or feelings back to the client Allowing time for formulating thoughts Communication

12 12 Approval/Disapproval Asking excessive questions Changing the subject Close-ended questions Giving advice False reassurance Value judgments Why questions Minimizing the client’s feelings Non-therapeutic Communication Techniques Communication

13 13 NCLEX Communication Question Guidelines Look for the option that indicates the use of a therapeutic communication technique. Eliminate non-therapeutic communication techniques. Look for the option that focuses on feelings, concerns, anxieties or fears. Consider cultural differences as you answer the questions.

14 14 Impact of Preexisting Conditions Both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted. Values, attitudes, and beliefs. Attitudes of prejudice are expressed through negative stereotyping. Culture or religion. Cultural mores, norms, ideas and customs provide the basis for ways of thinking. How do these affect the relationship?

15 15 Impact of Preexisting Conditions Social status. High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status. Gender. Masculine and feminine gestures influence messages conveyed in communication with others.

16 16 Impact of Preexisting Conditions Age or developmental level. The influence of developmental level on communication is especially evident during adolescence, with words such as “cool,” “awesome” and others.

17 17 Impact of Preexisting Conditions The environment in which the transaction takes place. Territoriality, density, and distance are aspects of environment that communicate messages. Territoriality – the innate tendency to own space Density – the number of people within a given environmental space Distance – the means by which various cultures use space to communicate

18 18 With regard to communication, there are three cultural characteristics to consider: Communication style Use of eye contact The meaning of touch The goal is to promote cultural sensitivity and culturally competent care that respects each person’s right to be understood and treated as a unique individual. Communication Cultural Considerations

19 19 Communication Style African Americans Personal questions asked on initial contact may be viewed as intrusive Communication Cultural Consideration

20 20 Communication Style Asian cultures  Open expression of emotions not valued  Silence is valued  Criticism or disagreement not expressed  Head nodding does not necessarily mean agreement  May interpret the word “no” as disrespect for others  Do not use hand gestures Communication Cultural Consideration

21 21 Communication Style Americans of Northern European descent  Silence can be used to show respect or disrespect, depending on situation  May show little facial emotion because they value concept of self-control Communication Cultural Consideration

22 22 Communication Style French and Italian Americans  May use expressive hand gestures and animated facial expressions Communication Cultural Consideration

23 23 Communication Style Hispanic Americans  May use dramatic body language such as gestures or facial expressions to express emotion or pain  Confidentiality important  Direct confrontation disrespectful, and expression of negative feelings impolite Communication Cultural Consideration

24 24 Communication Style Native Americans  Silence indicates respect for the speaker  Speak in a low tone of voice and expects others to be attentive  Body language is important  Obtaining input from extended family important Communication Cultural Consideration

25 25 Use Of Eye Contact Asian Cultures  Eye contact is limited and may be considered inappropriate or disrespectful Communication Cultural Consideration

26 26 Use Of Eye Contact European (White) Americans  Eye contact viewed as indicating trustworthiness Native Americans  Eye contact may be viewed as a sign of disrespect  Client may be attentive even when eye contact is absent Communication Cultural Consideration

27 27 Use Of Eye Contact Hispanic Americans  Avoiding eye contact with a person in authority indicates respect and attentiveness Communication Cultural Consideration

28 28 Meaning of Touch African Americans Comfortable with close personal space when interacting with family and friends European (White) Americans  Tend to avoid close physical contact  Respect personal space Communication Cultural Consideration

29 29 Meaning of Touch Asian Cultures  Prefer formal personal space except with family & close friends  Usually do not touch others during conversation  Touching unacceptable with members of the opposite sex; if possible, a female client prefers a female health care provider  The head is considered to be sacred; touching someone on the head may be considered disrespectful  Avoid physical closeness and excessive touching and only touch a client’s head when necessary, informing before doing so Communication Cultural Consideration

30 30 Meaning of Touch Hispanic Americans  Comfortable with close proximity with family, friends and acquaintances  Protect privacy  Tactile and sensory are important - use embraces and handshakes  Ask if it would be all right to touch a child before examining him or her Communication Cultural Consideration

31 31 While communicating with a client, a nurse decides to provide the client with feedback. The primary reason for this is that giving appropriate feedback makes it possible for the nurse to: A. Present advice B. Explore feelings C. Provide information D. Explain behavior Practice Question - Communication

32 32 Overview of Psychiatric Mental Health Nursing Mental Health The ability to see oneself as others do Fit into one’s culture and society Indicators of mental health Positive attitudes toward self, growth, development, self actualization, integration, autonomy, reality perception and environmental mastery.

33 33 Overview of Psychiatric Mental Health Nursing Mental Illness Inability to see as others do Not having the ability to conform to the norms of the culture and society

34 34 Overview of Psychiatric Mental Health Nursing Medical Diagnosis of Mental Illness Classified according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), of the American Psychiatric Association.

35 35 Overview of Psychiatric Mental Health Nursing The DSM-IV Classification system uses five axes for diagnostic purposes: Axis I: Adult and child clinical disorders Axis II: Personality disorders; mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning (0-100)

36 36 Mental Health Nurses Need both general and specific cultural knowledge If above absent, nurses won’t know what questions to ask Generalizations made are almost certain to be oversimplifications

37 37 Mental Health Nurses Must first address their own personal and professional knowledge, values, beliefs, ethics and life experiences in a manner that optimizes assessment of and interactions with culturally diverse clients

38 38 Mental Health Nurses Self awareness includes a deliberate process of getting to know oneself; one’s own personality, values, beliefs, professional knowledge, standards, ethics and the impact of the various roles one plays when interacting with individuals who are different from oneself.

39 39 Overview of PMHN Duties/Responsibilities Psychiatric Mental Health Nurses (PMHNs): Assess, formulate nursing interventions, and implement individualized treatment plans with culturally competent interventions. Document progress. Document changes. Attend interdisciplinary meetings to discuss progress, issues and treatment updates. Complete assault prevention training and other required trainings.

40 40 Overview of PMHN Duties/Responsibilities Uphold professional standards of behavior, appearance, language, dress and demeanor. As a member of an integrated treatment team, assist families, agency representatives and other staff. Understand the legal framework for the delivery of mental health services.

41 41 Nursing Process Assessment Nsg Dx Outcome ID Planning Implementation Evaluation Gathering and organizing data Identify (ID) areas for intervention Setting outcome criteria Planning action to meet the goals Carrying out actions Evaluating if goals (outcomes) are met

42 42 Mental Health Assessment INTERVIEW During the interview, the nurse uses verbal and nonverbal therapeutic communication techniques to collect subjective and objective data about the client.

43 43 Mental Health Assessment Purpose Establish rapport Determine reason client is seeking help Obtain an understanding of current illness (via client, family, chart review and interdisciplinary team) Understand how this illness has affected client’s life Identify client’s recent life changes or stressors

44 44 Gather current life style information Social patterns Interests and abilities Relationship issues Substance use and abuse Mental Health Assessment

45 45 Mental Health Assessment Assess for risk factors Suicide or self-harm Assault or violence Physiological instability

46 46 Mental Health Assessment Appraisal of health and illness Info on previous psychiatric problems or or disorders Current and past medications Physiological coping responses Psychological coping responses Resources

47 47 Nursing Conditions During Assessment Self-awareness Accurate observations Therapeutic communication Establish nursing contract Obtain information Organize data

48 48 Analyze Data/Norms Formulate Nursing Diagnoses Identify patterns in data Compare with norms Analyze and synthesize data Identify problems and strengths Validate problems with client Formulate nursing diagnoses Set priorities of problems

49 49 Outcome Identification (Goals) Identify expected outcomes individualized to client Planning Interventions to attain outcomes Nursing Conditions Application of theory Nursing Behaviors Prioritize goals Identify nursing activities Validate plan with client/family Key Elements Individualized, collaborative, documented

50 50 Implementation Implements interventions identified in the plan of care Experience Evidence-based practice Nursing behaviors Know available resources, implement, generate alternatives, coordinate with other team members

51 51 Evaluation Evaluation of progress in attaining expected outcomes An ongoing process Client and family participation essential Goal achievement should be documented Revisions in the plan of care PRN

52 52 Levels of Intervention Counseling Milieu therapy Self-care activities Psychobiological interventions Health teaching Case management Health maintenance and promotion Based on Nurse Practice Act

53 53 Nursing Interventions Form a trusting one-on-one relationship with the client Mutual learning experience for both the nurse and client Corrective emotional experience for the client Explore stressors Give constructive feedback Promote development of insight and constructive coping Overcome resistance behavior

54 54 Nursing Interventions Behavioral change is the focus Emphasize positive results Provide an environment that is safe and private with decreased stimuli as needed Ensure physical and psychosocial needs are met Encourage client participation in treatment planning Administer medications as ordered and assess results Educate client and family

55 55 Specific Nursing Interventions Active listening Anger control Assertiveness training Behavior management Body image enhancement Delusion management Eating disorders management Grief work facilitation Hallucination management Impulse control training Milieu therapy Mood management Role enhancement Sleep enhancement Spiritual support Substance abuse Tx Suicide prevention Teaching (meds…)

56 56 Legal and Ethical Issues Definitions Voluntary admission: Client consents to confinement in the hospital and signs a document indicating as much.

57 57 Legal and Ethical Issues Definitions Mental Health 72-hour Hold (“5150”): May be implemented on the basis that client poses a danger to self or others or is gravely disabled due to mental illness. Some states also have the criterion of prevention of significant physical or mental deterioration for involuntary admission. Police, doctors, psychologists, county-approved mental health professionals, nurses may initiate.

58 58 Criteria for Involuntary Confinement DANGER TO SELFDANGER TO OTHERSGRAVELY DISABLED (Due to mental illness) 72-hour hold (5150)72-hour hold 14-day certification (5250) 14-day certification Certification Review Hearing Writ of Habeas Corpus 14-day Extension90-day ExtensionTemporary conservatorship (30- day-6 months) 1 year conservatorship Rehearing Reappointment

59 59 Involuntary Confinement (continued) DANGER TO SELF ASSESSMENT DANGER TO OTHERS ASSESSMENT GRAVELY DISABLED ASSESSMENT Suicidal ideationHomicidal ideationsInability to provide food, clothing, shelter for self. Delusions or hallucinations which increase potential of suicide. Delusions or hallucinations which increase potential for harm to others. Amount of income, how it is spent Lethality Medical, psychological, educational, social and legal situation

60 60 Legal and Ethical Issues Definitions Competency: A legal determination that a client can make reasonable judgments and decisions about treatment and other significant areas of personal life.

61 61 Legal and Ethical Issues Informed consent: Client’s right to be given enough info to: Make a decision Understand the information Communicate his or her decision to others Receive explanation of client rights and unit policies Receive signed statement of understanding/refusal to receive Tx Receive explanation of insurance benefits or payment options/third-party reimbursement In an emergency situation, where there is not time to obtain consent without endangering health or safety a client may be treated without legal liability.

62 62 Client Rights/Nursing Responsibility Right to appropriate treatment Right to know qualifications of those involved in treatment process Right to receive explanations of treatment Right to be involved in planning of own care Right to refuse to be a part of experimental treatment methods Right to understand the effects of prescribed medication Right to treatment in least restrictive environment Right to refuse treatment - decide which treatment option is best for them

63 63 Legal and Ethical Issues Principle of Confidentiality Federal laws regarding chemical dependence confidentiality; staff members are not allowed to disclose any admission or discharge information. States have laws regarding when HIV test results or the diagnosis of acquired immunodeficiency syndrome (AIDS) may be disclosed.

64 64 Legal and Ethical Issues Principles of Confidentiality Client’s right Prevent written or verbal communications from being disclosed to outside parties without authorization Required by Nurse Practice Act HIPAA (Health Insurance Portability and Accountability Act of 1996 (2003) Ensures that security procedures protect the privacy and confidentiality of information Client has right to know what information is disclosed, to whom and for what purpose

65 65 Legal and Ethical Issues Required disclosure Intent to commit a crime Duty to warn endangered persons Evidence of child, elder, vulnerable adult abuse Initiation of involuntary hospitalization

66 66 An adult client says, “No, I don’t want that medicine. I won’t take it.” The nurse says, “Take it. It’s good medicine.” The nurse then places the cup in front of the client’s mouth and forcefully presses it against the client’s lips. In counseling this nurse, what important legal principle(s) can be applied to the nurse’s action? Select all that apply. A. If a client does not object a second time, a nurse can administer the medication. B. If treatment is given without consent, legal charges of battery can be filed. C. Clients have the right to be treated in the least restrictive manner possible. D. Clients, unless declared legally incompetent, have the right to refuse medication. E. Clients who wish to do so may establish psychiatric advance directives.

67 67 A client has purposefully attempted to embarrass a nurse by making a sexually explicit comment. The best response by the nurse is to: A. Clarify the intention of the client. B. Leave the situation altogether. C. Refuse to talk with the client any further. D. Continue to interact as if the comments did not cause embarrassment.

68 68 Crisis Definition of Crisis Being confronted by a stress with which the individual is unable to cope/problem-solve Threatens the individual’s equilibrium Generally time limited, lasting from 4 to 6 weeks Potential for increased psychological vulnerability or personal growth

69 69 Crisis Interventions Establish a relationship Identify the problem Identify and reduce perceptual distortions Enhance self-esteem Alleviate anxiety Promote engagement of support systems Reinforce healthy coping Validate client’s ability to problem-solve. Keep safe if at risk for suicide

70 70 A client seeks assistance at a crisis center. The client describes being intensely anxious and sleepless since assisting with cleanup activities at a school where a student fatally shot a classmate. To assist the client to cope more effectively, what should be the first intervention of the nurse? A.Arrange for a member of the clergy to visit the client B.Advise the client to avoid going near the school for at least 6 weeks C.Send the client to the Emergency Department for further evaluation D.Allow ventilation of feelings

71 71 When the nurse is working with a client in crisis, which nursing action is most important? A. Obtaining a complete assessment of the client’s past history B. Remaining focused on the client’s immediate problem C. Determining the relationship of early life experiences and the crisis state D. Developing an action plan for the client

72 72 Suicide Prevention Assessment Determine suicidal ideation Evaluate how client sought help Suicide plan? Mental status Available support systems Lifestyle

73 73 Suicide Prevention Interventions Inpatient interventions Providing a safe milieu in which the client’s ability to act out on suicidal ideations is minimized

74 74 Suicide Prevention Safe Milieu (continued) Depending on the degree of suicidal ideation and lethality assessed Constant observation for 24 hours or until the degree of suicidal risk is lessened 15-minute checks thereafter Maintain awareness of the client’s whereabouts constantly

75 75 Suicide Prevention Safe Milieu (continued) Upon admission to the unit: Assess personal belongings and remove any items that could be used to harm client (drugs, potentially sharp objects, cords and neck ties) and keep them in a safe place.

76 76 Suicide Prevention Safe Milieu (continued)  Keep the unit free of materials that can be used by clients to harm themselves. For example, metal or glass objects that may be altered to create a sharp edge, light fixture or call bell cords Keep windows locked, count silverware, and check the client’s belongings when returning from a pass. Check gifts and other items brought in by visitors for safety before being given to the client.

77 77 Suicide Prevention Safe Milieu (continued) Develop a safety plan and assess frequently Oral check for hoarding medications for a later overdose Assign a roommate to reduce the opportunity for solitude Work with the client to identify an aftercare plan that includes: A commitment to attend aftercare appointments An agreement to maintain contact with social support systems Identification of a safety plan with emergency contact numbers An action plan should suicidal ideations return

78 78 Psychopharmacology Prevent Suicide Pharmacologic interventions Pharmacologic interventions aimed at treating: Underlying mood disorder Other psychiatric disorders Co-existing psychiatric disorders Depressive disorders treated with antidepressants SSRIs relatively low risk of lethal overdose Tricyclic antidepressants can be highly lethal in overdose Quantity of prescribed/dispensed kept at a minimum and may need to be managed by a family member

79 79 For the third time within a month, a client with borderline personality disorder took a handful of pills, called 911, and was admitted to the Emergency Department. The nurse overhears an unlicensed staff member say, “Here she comes again. If she was serious about committing suicide, she’d have done it by now.” The nurse determines there is a need to teach the staff member which of the following? A. Clients with personality disorders rarely kill themselves. B. Each suicide attempt should be taken seriously. C. Exploration of suicidal ideas and intent should be avoided. D. The nurse should prepare the client for direct inpatient admission.

80 80 A client has been treated in the surgical intensive care unit after sustaining a self-inflicted gunshot wound. The client is now admitted to a psychiatric unit. The nurse schedules time to meet with the client on a one-to-one basis with the goals that the client will: (Select all that apply.) A. Explore current life events that led to the suicide attempt. B. Initiate contact with the nurse spontaneously. C. Discuss past suicidal ideations and behavior. D. Enter into a contract for safety with the nurse. E. Identify post-discharge living arrangements.

81 81 Mental Health Therapies Inpatient Hospitalization Conditions for hospitalization: Dangerous to oneself or others Incapable of providing for one’s basic physical needs; gravely disabled In need of care or treatment in the hospital (voluntary)

82 82 Mental Health Therapies Milieu Therapy An environment designed to promote healing experiences and to provide a corrective setting for the enhancement of the client’s coping abilities. Includes: Correcting perceptions of stressors Changing coping mechanisms from maladaptive to adaptive Improving interpersonal relationship skills Learning effective stress management strategies

83 83 Mental Health Therapies Critical Issues Boundaries define functions in the therapeutic relationship and imply responsibility. The nurse must clarify/maintain boundaries to make the client more at ease in the new relationship and environment.

84 84 What Is Child Abuse? Definition Child abuse: Any act of omission or commission that endangers or impairs child’s physical or emotional health and development. Sexual Abuse: Victimizer uses victim for sexual gratification & victim incapable of consenting to this sexual activity or of resisting when it occurs. Physical Abuse: Deliberate violent actions that inflict pain and/or non-accidental injury.

85 85 What Is Child Abuse? Child Abuse  Physical neglect - Deprivation or non-provision of necessary & socially-available resources  Psychological abuse - Deliberate destruction of a person’s sense of competence

86 86 Elder Abuse Elder abuse Mistreatment or neglect of an elderly person Most victims are women 75 years of age or older Victims usually physically, emotionally or financially dependent on their abusers Types: Psychological abuse Physical abuse Neglect (intentional or unintentional) Financial or material abuse

87 87 Mandated Reporters: Abuse Mandated Reporters  Nurses who suspect abuse of children, dependent adults or elders must report it.  You must immediately call and report the suspected abuse.  A follow-up written report is required within two working days.  Failure to report abuse is a misdemeanor.

88 88 A 5-year-old girl is brought to the clinic for symptoms of a urinary tract infection (UTI). The nurse’s assessment reveals bruises in the child’s genital and rectal areas. The mother reports that she left the little girl with her boyfriend the night before. The nurse’s first priority with this client is to take what action? A. Obtain a urine sample to confirm a UTI. B. Teach the mother about symptoms of UTI. C. Report suspected sexual abuse to protective services. D. Assess the child for other health problems.

89 89 An 85-year-old client is brought into the Emergency Department after a fall at home. The client appears confused and malnourished and is severely dehydrated. The client can speak but appears reluctant to explain how the fall happened. The client’s 62-year-old daughter frequently interrupts the client and does not allow the client to answer questions. Which of the following nursing interventions is a priority? A. Take the history from the daughter because the client is confused. B. Provide the daughter with nutritional teaching. C. Request a psychiatric evaluation for the client. D. Interview the client alone first and assess for abuse.

90 90 Protection in the Mental Health Setting - Restraints Restraints Seclusion – placement of client in controlled environment to treat a clinical emergency Physical restraint – use of mechanical devices to provide limited movement by client Chemical restraint – use of medication to calm client and prevent need for physical restraint

91 91 Protection in the Mental Health Setting- Restraints Restraints Physical restraint appropriate after all other types of interventions are used to assist the client to control his/her behavior and remain safe Documentation of all interventions and results are critical

92 92 Protection in the Mental Health Setting- Restraints Restraints Legal Implications Physician’s order is a necessity Facility rules and state laws Liability for false imprisonment Liability for assault and battery KNOW LIMITATIONS OF THE LAW!

93 93 Documentation should include: Description of a clear process from less restrictive interventions Criteria for a removal of restraints Care and observation during the use of restraints Regular assessment of the client and potential complications of restraints Reasons for removal of restraints Follow-up interventions, including processing with client, event leading to restraint. Protection in the Mental Health Setting - Restraints

94 94 Photo Acknowledgement: All unmarked photos and clip art contained in this module were obtained from the 2003 Microsoft Office Clip Art Gallery.


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