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Pharmacology and Alternative Therapies
PVN123 – Mental Health Nursing - Presentation #4 Pharmacology and Alternative Therapies
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Objectives Identify common medications used to treat mental disorders (ATI Tutorial 2011B) Identify expected pharmacological actions Identify therapeutic uses Identify side/adverse effects Identify contraindications and precautions Identify food and medication interactions Identify patient teaching strategies Identify Traditional Non-pharmacological Therapies for the treatment of mental health disorders
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Psychopharmacological Therapies
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How to Access the ATI Pharmacology Tutorial (2011B) -(Quiz #2)
Click on the link below for a video message from your instructor.
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Complete the Tutorial! (due beginning of Day 3)
ATI Tutorial (Course Quiz #2) Pharmacology Made Easy 2.0 ID = TU Password = 15F7U Module = The Neurological System (Part 2) Here’s a Link to the ATI Website!
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Alternative Therapies
Psychoanalysis / Psychotherapy / Behavioral Therapies Group and Family Therapy Stress Management Electroconvulsive Therapy
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Psychoanalysis Psychotherapy Behavioral Therapies
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Psychoanalysis / Psychotherapy / Behavioral Therapies
Approaches to addressing mental health issues using various methods and theoretical bases Nurses should be familiar with methods employed!
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Psychoanalysis Assessing unconscious thoughts and feelings
Resolving conflict through talking to psychoanalyst Many sessions over months to years Not usually sole therapy of choice Lengthy duration and insurance constraints First developed by Sigmund Freud Past relationships are common focus Therapeutic Tools Used: Free Association Spontaneous/uncensored verbalization of whatever comes to mind Dream Analysis Transference Feelings that client has developed toward therapist related to someone else from early childhood Use of defense mechanisms
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Psychotherapy More verbal therapist/client interaction than traditional psychoanalysis Trusting relationship between client and therapist Includes: Psychodynamic Psychotherapy Interpersonal Psychotherapy (IPT) Cognitive Therapy Behavioral Therapy Cognitive Behavioral Therapy
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Psychotherapy Psychodynamic Psychotherapy
Same tools as Psychoanalysis But!.... Oriented more to client’s present state than early life Interpersonal Psychotherapy (IPT) Used for clients with specific problems Can improve interpersonal relationships / communication / role-relationship / bereavement Cognitive Therapy Based on cognitive model – focuses on individual thoughts/ behaviors to solve current problems. Used to treat depression / anxiety / eating disorders / other issues that require changing attitude toward life experiences Behavioral Therapy Focuses on changing behavior Based on theory that behavior is learned and has consequences Abnormal behavior is result of avoiding painful feelings Teaches clients to decrease anxiety or avoidant behavior Used successfully to treat phobias / addictions Cognitive Behavioral Therapy Uses both cognitive and behavioral approach Used in anxiety management
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Cognitive Therapy Anxiety decreased by changing cognitive distortions
Cognitive Reframing identify negative thoughts that produce anxiety Examine the cause Develop supportive ideas Priority Restructuring identifying priorities Journal Keeping writing down stressful thoughts Assertiveness Training expressing feelings and solving problems in nonaggressive manner Monitoring Thoughts becoming aware of negative thinking
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Behavioral Therapy Type Definition Use in MH Nursing Modeling
Therapist serves as role model for client Improving interpersonal skills Therapist demonstrates behavior in stressful situation Goal is for client to imitate the behavior Operant Conditioning Positive rewards for positive behavior Ex: tokens given for good behavior which can be exchanged for a privilege or other items Systematic Desensitization Planned, progressive, or graduated exposure to anxiety provoking situations and stimuli Real life situations or imagining events Anxiety response is suppressed through relaxation techniques Client masters relaxation techniques Client exposed to increasing levels of anxiety-producing stimulus Relaxation used to overcome anxiety Client then able to tolerate greater and greater level of stimulus Aversion Therapy Maladaptive behavior paired with a punishment or unpleasant stimuli Therapist uses unpleasant stimuli as punishment for undesirable behaviors Bitter taste/mild electric shock Medication / guided imagery/ diaphragmatic breathing / muscle relaxation / biofeedback Techniques used to control pain / tension / anxiety Ex: Reinforced teaching about diaphragmatic breathing for client having a panic attack.
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Behavioral Therapy Other techniques Flooding Response Prevention
Exposing (in presence of therapist) to a great deal of an undesirable stimulus Attempt to “turn off” anxiety response Response Prevention Prevent client from performing compulsive behavior Intent is that anxiety will be diminished Thought Stopping Teaching client to shout the word “STOP” when negative thoughts or compulsive behaviors arise Over time the client will use the command silently
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Quick Quiz! A client states that he is depressed because he has had to deal with role reversal with his spouse after the loss of his job due to a disability. Which of the following therapies would the nurse expect to help implement for the client? A. Operant conditioning B. Systematic desensitization Psychodynamic psychotherapy Interpersonal psychotherapy
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Quick Quiz! Answer Psychoanalysis A
Psychoanalysis A A client who has had heated disputes with other clients on the unit learns to solve problems by sitting down and talking calmly and reasonably with other clients. Cognitive Technique B The client discusses his dreams with the therapist. Assertiveness Training C The client is encouraged to stop sucking his thumb by having a bitter liquid applied to his thumb. Aversion Therapy D A client who feels awkward in group social situations watches a video showing some positive ways to interact in groups. Modeling E A client who displayed violent behavior in the past and felt negative about herself, learns to think and speak about herself in more positive terms.
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Group and Family Therapy
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Group and Family Therapy
Open therapeutic communication Participants willing to be involved Part of treatment plan for clients in mental health setting Guided by leaders Leadership styles include: Democratic Supports group interaction and decision making to solve problems Laissez-faire Group progresses with no attempt by the leader to control the direction of the group Autocratic Leader completely controls the direction and structure of the group No group interaction or decision-making to solve problems
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Group Therapy
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Watch a Video Group Therapy Isn’t…
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Group Therapy Verbal and nonverbal communication occurring within group sessions Group Norm The way the group behaves during sessions Provides structure for the group Hidden Agenda Some group members (or leader) have goals different from the stated group goals May disrupt group progress Subgroup Small number of people within a larger group Function separately from the group Groups may be open or closed Open groups – new members added as old members leave Closed groups – no new members added after the group is formed
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Group Therapy Homogenous group Therapy sessions include
All members share a certain characteristic Ex: diagnosis or gender Therapy sessions include Use of open and clear communication Cohesiveness and guidelines Direction toward a goal Opportunity for development of: Interpersonal skills Resolution of personal / family issues Relationship development Communication regarding respect among members Support and education regarding community support resources
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Group Therapy Group Therapy Goals:
Sharing of common feelings / concerns Sharing of stories / experiences Diminishing feelings of isolation Creating a community of healing and restoration Providing more cost-effective environment than individual counseling Group therapy may be used for varying age groups: Children play while talking about a common experience Adolescents Especially valuable due to strong peer relationships Older Adult Helps with socialization and sharing memories
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Group Therapy Roles Maintenance Roles Task Roles Individual Roles
Members maintain the purpose and process of the group Ex: harmonizer Attempts to prevent conflict within the group Task Roles Members take on various tasks within the group process Ex: recorder Takes notes or records of what occurs Individual Roles Individuals take roles to promote their own agenda Prevents teamwork Ex: dominator Tries to control other members
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Family Therapy
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Family Therapy Family defined as a group with reciprocal relationships
Members are committed to each other Family Therapy Focus is on the family as a system rather than members as individuals Family assessments include focused interviews and use of various family assessment tools Nurses work with families to: Provide teaching Mobilize family resources Improve communication Strengthen ability to cope with illness of one member
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Characteristics of Families
Area of Functioning Healthy Families Dysfunctional Families Communication Clear understandable messages between family members Each member encouraged to express individual feelings and thoughts One or more members use unhealthy patterns Blaming Manipulating Placating Distracting Management Adults of family agree on important issues Rule-making Finances Plans for the future Management may be chaotic Child making management decisions at times Boundaries Distinguishable boundaries between family roles Clear boundaries defined for each member Boundaries understood by all Each member can function appropriately Enmeshed boundaries Thoughts/roles/feelings are so blended that individual roles are unclear Rigid boundaries Rules and roles are inflexible Family tends to have isolated members Socialization All members interact / plan / adopt healthy ways of coping Children learn to function as family and society members Members can change as the family grows and matures Children do not learn health socialization skills within the family Have difficulty adapting to socialization roles in society Emotional/Supportive Emotional needs of family and members are met most of the time Members are concerned about each other Conflict and anger do not dominate Negative emotions predominate most of the time Members are isolated and afraid Do not show concern for each other
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Concepts Related to Family Dysfunction
Scapegoating A member of the family has little power Blamed for problems in the family Triangulation Third party is drawn into the relationship with two members whose relationship is unstable Multigenerational Issues Emotional issues within the family that continue for at least three generations Addiction patterns when family under stress Dysfunctional grief patters Triangulation patterns Divorce
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Focus and Goals Individual / Family / Group Therapies
Therapy Focus Goals Individual Client needs and problems The therapeutic relationship Make more positive individual decisions Make productive life decisions Develop a strong sense of self Family Family needs and problems Improving family relationships Learn effective ways for dealing with mental illness within the family Improve understanding among family members Maximize positive interaction among family members Group Help individuals develop functional and satisfying relations within a group setting Goals depend on type of group Clients generally: Discover that members share common feelings / experiences / thoughts Experience positive behavior changes as result of group interaction and feedback
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Watch a Video Structural family therapy example
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Quick Quiz! A nurse leading a stress management group demonstrates that he supports group interaction and the decision-making required to solve problems. The group proceeds with all members feeling that they have input into the group’s decisions. Which leadership style does this illustrate? A. Democratic B. Laissez-faire C. Autocratic D. Authoritative
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Quick Quiz! A nurse is conducting a family therapy session. The teenage son tells the nurse that his parents will punish him harshly if he discloses anything in the session about the family’s arguments at home. The parents have never made any such threats to him. This is an example of which of the following? A. placation B. manipulation C. blaming D. distraction
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Stress Management
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Stress Body’s nonspecific response to any demand made upon it
Stressors Physical Psychological Produces a biological response in the body Some stressors are needed to provide interest and purpose Too much stress or too many stressors can cause distress Anxiety and anger are damaging stressors that cause distress General Adaptation Syndrome (GAS) Body’s response to an increased demand First stage = “Fight or Flight” mechanism If prolonged, maladaptive responses may occur
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Stress Management The person’s ability to experience appropriate emotions and cope with stress Healthy management of stress Flexible Uses a variety of coping techniques and mechanisms Responses to stress/anxiety affected by: Age Gender Culture Life experiences Lifestyle Effects of stressors are cumulative
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Protective Factors Things that increase ability to resist the effects of stress Physical health Strong sense of self Religious/spiritual beliefs Optimism Hobbies and other outside interests Satisfying interpersonal relationships Strong social support systems Humor
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Subjective and Objective Data
Acute Stress “Fight or Flight” Prolonged Stress (maladaptive responses) Apprehension Chronic anxiety or panic attacks Unhappiness / sorrow Depression / chronic pain / sleep disturbances Decreased appetite Weight gain or loss Increased respiratory rate / heart rate / cardiac output / BP Increased risk for myocardial infarction / stroke Increased metabolism and glucose use Poor diabetes control / hypertension / fatigue / irritability / decreased ability to concentrate Depressed immune system Increased risk for infection
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Standardized Screening Tools
Life-Changing Events Questionnaires Holmes Rahe Stress Scale (see handout) Lazarus’s Cognitive Appraisal
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Nursing Care Reinforce teaching of stress reduction strategies
Cognitive Retraining Help clients look at irrational thoughts in a more realistic light and restructure thoughts in a more positive way. Behavioral Techniques Relaxation techniques Meditation Guided imagery Breathing Exercises Progressive Music Relaxation (PMR) Physical Exercise Journal Writing Priority Restructuring Biofeedback Assertiveness Training Client Outcomes Client will verbalize stressors and ways to decrease exposure Client will demonstrate appropriate relaxation techniques Client will demonstrate assertive communication
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Quick Quiz! Scenario: List the stressors that affect this client.
A client speaking to a nurse in a general medical clinic, describes herself as feeling anxious, apprehensive, and tired all the time. She says she cannot understand why, since she is very happy. She recently moved to the area to start a new job for a large corporation. She purchased a new and much larger home for herself and her three children (ages 5, 8, and 12). The children transitioned to their new schools successfully and are making friends. The client’s family and friends are all back in the previous city where she lived, but she has been so busy with work that she has not had time to telephone or write to them. The client states she has not been able to sleep and has lost weight in the 2 months since the move. List the stressors that affect this client. 2. Which of the client’s manifestations of increased stress reflects acute Stress rather than prolonged stress? Weight loss Apprehension Fatigue Insomnia
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Electroconvulsive Therapy
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Watch a Video Electroconvulsive Therapy
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Electroconvulsive Therapy (ECT)
Alternative somatic treatment for mental health disorders Delivers an electrical current that produces a grand mal seizure The exact mechanism of ECT is still unknown and controversial May enhance the effects of neurotransmitters in the brain Serotonin Dopamine norepinephrine
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Indications for ECT Severe depression Some types of Schizophrenia
Symptoms not responsive to pharmacological treatment If risks of other treatments outweigh those of ECT First trimester of pregnancy Actively suicidal Need for rapid therapeutic response Some types of Schizophrenia If less responsive to neuroleptic medications Catatonic schizophrenia Schizoaffective disorder Acute manic episodes For bipolar clients with rapid cycling and very destructive behavior Four or more episodes of acute mania within 1 year Both features usually do not respond well to Lithium therapy
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Contraindications for ECT
No absolute contraindications if deemed necessary to save / improve a client’s life Medical conditions for high risk with ECT Recent myocardial infarction History of cerebrovascular accident Cerebrovascular malformation Intracranial mass lesion Medical conditions for which ECT is useful: Developmental disabilities Chemical dependence Personality disorders Situational depression
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Nursing Actions Prepare the client Use therapeutic communication
Typical course of treatment is 3 x /week for 6 – 12 treatments Use therapeutic communication Physician will discuss the procedure and obtain informed consent Risks and benefits Guardian gives consent if client incompetent Sometimes separate informed consent for anesthesia History and physical examination Neuro exam Electrocardiogram (ECG) Lab tests
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Nursing Actions Medication Management
Meds that affect client’s seizure threshold are decreased or discontinued several days before ECT procedure. MAOIs and lithium should be DC’d 2 weeks before the procedure Severe hypertension is controlled Short period of hypertension post procedure Monitor vital signs Monitor mental status Ask client and family about understand and knowledge of the procedure Redirect to MD for clarification as needed IV inserted and maintained until full recovery IM injection of atropine sulfate or glycopyrrolate (Robinul) is given 30 minutes prior to procedure to decrease secretions and counteract vagal stimulation.
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Nursing Actions – During Procedure
ECT administered in early morning After 8 – 12 hours of fasting Client uses bite guard to prevent oral cavity trauma Electrodes are applied to the scalp The client is mechanically ventilated and receives 100% oxygen Ongoing cardiac monitoring provided BP / heart rate and rhythm / oxygen saturation Short acting anesthetic (Brevital) is provided IV bolus Muscle relaxant (Anectine) is administered Cuff placed on one leg or arm Blocks muscle relaxant so seizure activity can be monitored and documented Duration of seizure is usually 25 to 60 seconds After seizure activity is ceased, anesthetic is discontinued Client is extubated and assed to breathe voluntarily
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Nursing Actions – Post Procedure
Client is transferred to recovery area Assess: LOC Cardiac status Vital signs Oxygen saturation Position client on side to facilitate drainage and prevent aspiration Client is usually awake are ready for transfer back to the mental health unit within 30 to 60 minutes after the procedure Orient client frequently Confusion and short-term memory loss are common Continue to monitor vital signs and mental status for memory loss
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Complications of ECT Memory loss and confusion
Short term memory loss May persist for several weeks If ECT causes permanent memory loss is controversial Confusion Disorientation Explain to clients and families that memory loss is typically short term Assist client with memory Clock in the room Label client’s room location Headache / muscle soreness / nausea Observe degree of discomfort Administer antiemetic and analgesic medication as needed Explain the reason for clinical manifestations Encourage clients to contact nurse regarding these symptoms
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Summary Identified common medications used to treat mental disorders (ATI Tutorial 2011B) Identified expected pharmacological actions Identified therapeutic uses Identified side/adverse effects Identified contraindications and precautions Identified food and medication interactions Identified patient teaching strategies Identified Traditional Non-pharmacological Therapies for the treatment of mental health disorders
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Assignment See Schedule for assignments due for next class
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Next Class ATI Tutorial (Quiz #2) due! Mid Term Evaluations Q&A
Special Populations and Mental Health Issues (Ppoint Presentation and Study Guide #5) Nursing Process and Care Plan Development for Mental Health ATI Practice Test #2 Be sure to practice before test!! Grade on practice will be averaged with your graded test
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We’re halfway there! Keep up the great job!!!
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