NCLEX-RN: Psychiatric Nursing

Psychiatric Nursing: Recovery

Focus topic: Psychiatric Nursing

A. People with mental health (MH) disorders get better with treatment.
B. Substance Abuse and Mental Health Services Administration (SAMHSA).

  • Defines recovery as process of change through which individuals a. Improve their health and wellness.
    b. Live a self-directed life.
    c. Strive to reach full potential.
  •  Identifies four dimensions that support recovery:
    a. Overcoming/managing disease (living in a healthy way).
    b. A stable/safe place to live.
    c. Meaningful daily activities.
    d. Supportive relationships and networks.
  •  Psychiatric nursing practice supports recovery.
  •  Psychiatric nursing care should be client- and family-centered.

 

Psychiatric Nursing: Key Organizations/Concepts

Focus topic: Psychiatric Nursing

A. Organizations:

  •  SAMHSA.
  •  National Alliance for the Mentally Ill (NAMI).
  •  American Psychiatric Nurses Association (APNA).
  •  The Joint Commission.
    a. Hospital-based inpatient psychiatric services (HBIPS) core measure.
    (1) Admission screening for violence, trauma, client strengths.
    (2) Hours of seclusion and restraints.
    (3) Clients discharged on multiple anti-psychotic medications (and with justification).
    (4) Continuing care plan at time of discharge.
    (5) Continuing care plan transmitted to next level of care.
    b. Behavioral health care national client safety goals.
    (1) Identify individuals served correctly— two client identifiers.
    (2) Use medicines safely—medication reconciliation.
    (3) Prevent infection—Centers for Disease Control and Prevention (CDC) or World Health Organization (WHO) hand hygiene guidelines.
    (4) Identify safety risks—identify individuals at risk to try or commit suicide.

B. Ruling out medical conditions as etiology for psychiatric conditions is always the first step in evaluation. Thorough nursing assessment and interview is integral to the process.

Psychiatric Nursing: Mental Status Assessment

Focus topic: Psychiatric Nursing

The mental assessment is completed throughout the physical assessment and history-taking time frame. It is not generally considered a separate entity. Mood, memory, orientation, and thought processes can be evaluated while obtaining the health history.
The purpose of a mental status assessment is to evaluate the present state of psychological functioning and to determine if there is an immediate risk of harm to self or others, or deficit in ability to care for self as a result of mental health issues. It is not designed to make a diagnosis; rather, it should yield objective data that will contribute to the total picture of the client as he or she is functioning at the time the assessment is made. (See Table 14-1.)
The initial factors that the nurse must consider in completing a mental status assessment are to correctly identify the client, the reason for admission, record of previous mental illness, present complaint, any personal history that is relevant (living arrangements, role in family, interactional experience), family history if appropriate, significant others and available support systems, assets, and interests.
A spiritual assessment can be obtained as a part of the health history, although specific sociocultural beliefs may need to be ascertained separately. The purpose of a spiritual assessment is to facilitate the client adapting to the hospital environment and help the staff understand stressors the client may be experiencing as a result of belief systems.
The actual assessment process begins with an initial evaluation of the appropriateness of the client’s behavior and orientation to reality. The assessment continues by noting any abnormal behavior and ascertaining the client’s chief verbalized complaint. Finally, the evaluation determines if the client is oriented to reality enough to answer particular questions that will further assess the client’s condition.

Psychiatric Nursing

Psychiatric Nursing: MENTAL STATUS ASSESSMENT

Focus topic: Psychiatric Nursing

 Psychiatric Nursing
Psychiatric Nursing
Psychiatric Nursing

Whenever findings are abnormal, either initially or during treatment, etiology should be explored (e.g., laboratory test results, vital signs, physical assessment findings).
Nursing plan of care should reflect mental status findings and changes as identified, if significant.

Psychiatric Nursing: The Nurse–Client Relationship

Focus topic: Psychiatric Nursing

Definition: The nurse–client relationship is a dynamic, therapeutic, professional relationship in which interaction occurs between two persons the nurse, who possesses the skills, abilities, and resources to relieve another’s discomfort, and the client, who is seeking assistance for alleviation of some existing problem or need.

Principles Underlying Relationship Therapy
A. The client’s value as a unique individual with physical and psychosocial needs must be acknowledged.
B. The nurse’s level of self-awareness, understanding of human interaction and relevant theories, and needs enhances the development of the therapeutic relationship.
C. Some degree of emotional involvement is required, but objectivity and adherence to professional communication and boundaries on the part of the nurse must be maintained.
D. Appropriate limits must be set, and consistency must be maintained.
E. Empathic understanding is therapeutic; sympathy is non-therapeutic.
F. Honest, open, genuine, and respectful communication is basic to the therapeutic process.
G. Expression of feelings, within safe limits, should be encouraged.

Phases in Nurse–Client Relationship Therapy
A. Preinterview phase.

  • Prepare for first encounter by reviewing available information.
  •  Evaluation one’s feelings, fears, beliefs.

B. Initiation or orientation phase.

  •  Establish boundaries of relationship.
  • Assess anxiety levels of self and client.
  •  Identify expectations/needs of client.
  •  Identify problems; set goals of the relationship.
  •  Responsibilities of client and nurse are defined.
  •  Confidentiality is stressed.

C. Continuation or active working phase.

  •  Promote attitude of acceptance and trust of each other to maintain therapeutic relationship.
  •  Use specific therapeutic and problem-solving techniques to develop working relationship.
  •  Continually assess and evaluate problems.
  •  Focus on increasing client’s independence and promoting the client’s problem-solving skills.
  •  Maintain the goal of client’s confronting and working through identified problems to facilitate change.

D. Termination phase.

  • Plan for the conclusion of therapeutic relationship early in the development of relationship.
  •  Maintain initially defined boundaries.
  • Anticipate problems of termination.
    a. Client may become too dependent on the nurse. Encourage client to become independent.
    b. Termination may cause client to recall previous separation experiences, feelings of abandonment, rejection, anger, and depression.
    c. Discuss client’s previous experiences and help work through any negative ones.
  •  Discuss client’s feelings about termination.
  •  Summarize the goals and objectives achieved.

Assessment
A. Determine purpose of establishing a nurse–client relationship.
B. Assess the overall condition of the client to determine what benefits will be derived from a nurse client relationship.
C. Observe what is happening with the client here and now.
D. Identify developmental level of client so relationship goals will be realistic.
E. Determine whether client exhibits verbal or nonverbal communication patterns so the nurse can respond therapeutically.
F. Assess anxiety level of client.
G. Identify client expectations of a therapeutic relationship and describe parameters of the relationship.
H. Examine your own feelings and expectations that may potentially impact the development of a therapeutic relationship.

Implementation
A. Assume the role of facilitator in the relationship.
B. Accept client as having value and worth as a unique individual.
C. Maintain relationship on a professional, therapeutic level.
D. Ensure appropriate, safe environment for interaction

E. Establish or identify time frame for interaction if required.
F. Provide an environment conducive to client’s receiving healing, supportive emotional experiences.
G. Keep interaction reality oriented that is, in the here and now.
H. Listen actively, reflect feelings.
I. Use nonverbal communication to support and encourage client.

  •  Recognize meaning and purpose of nonverbal communication.
  •  Keep verbal and nonverbal communication congruent by identifying and exploring in congruent messages.

J. Focus content and direction of conversation on client.
K. Interact on client’s intellectual, developmental, and emotional level.
L. Focus on “how, what, when, where, and who” rather than on “why.”
M. Teach client problem-solving skills to correct maladaptive patterns.
N. Help client to identify, express, and cope with feelings; assist client to express thoughts and feelings that result in an emotional release (catharsis) and progression towards achievement of personal, recovery, and treatment goals.
O. Help client develop alternative, adaptive coping mechanisms.
P. Recognize a high level of anxiety and assist client to cope.
Q. Use therapeutic communication techniques.

  •  Use techniques to increase effective communication. (See Therapeutic Communication Techniques.
  •  Recognize blocks or barriers to effective communication and work to remove them. (See Blocks to Communication.

Psychiatric Nursing: THERAPEUTIC COMMUNICATION TECHNIQUES

Focus topic: Psychiatric Nursing

Psychiatric Nursing

Psychiatric Nursing: BLOCKS TO COMMUNICATION

Focus topic: Psychiatric Nursing

Psychiatric Nursing

Psychiatric Nursing: Therapeutic Communication Process

Focus topic: Psychiatric Nursing

Definition: Communication is a continuous, dynamic process of sending and receiving messages by means of symbols, words, signs, gestures, or other action. It is a multilevel process consisting of the content or information of the message and the part that defines the meaning of the message. Messages sent and received define the relationship between people. Therapeutic communication utilizes the principles of communication in a goal-directed professional framework.

Characteristics
A. A person cannot not communicate.
B. Communication is a basic human need.
C. Communication includes verbal and nonverbal expression (includes tone and quality of speech, manner of dress, use of space).
D. Successful communication includes

  •  Appropriateness.
  • Efficiency.
  •  Flexibility.
  •  Feedback.

E. Communication skills are learned as the individual grows and develops.
F. The foundation of the person’s perception of himor herself and the world is the result of communicated messages received from significant others.
G. High anxiety in both nurse and client impedes communication.
H. Self-awareness during the interview facilitates honest communication.
I. Factors that affect communication:

  •  Intrapersonal framework of the person.
  • Relationship between the participants.
  •  Purpose of the sender.
  •  Content of the message.
  •  Context of the message.
  •  Manner in which the message is sent.
  •  Effect on the receiver.
  •  Environment in which the interaction takes place.

J. Purpose of communication.

  • To transfer ideas from one person to another.
  •  To create meaning through the communication process.
  •  To reduce uncertainty, to act effectively, and to defend or strengthen one’s ego.
  •  To affect or influence others, one’s physical environment, and oneself.

Psychiatric Nursing: The Interview Process

Focus topic: Psychiatric Nursing

Assessment
A. Determine purpose of the interview.
B. As the first step in therapeutic interviewing, do an initial assessment of the client’s total condition physical, emotional, cognitive, spiritual, and social.
C. Observe accurately what is happening with client in the here and now.
D. Be aware of your own feelings, reactions, and level of anxiety.
E. Assess client’s communication patterns, behavior, and general demeanor.
F. Determine and assess life situation of client.
G. Assess environmental conditions that may affect nurse–client interaction.

Implementation
Components of Interview Process
A. Provide a safe, private, comfortable setting if possible. If utilizing an electronic workstation, refocus on client as much as possible.
B. Encourage client to describe perceptions and feelings.

  •  Focus on communication; offer leads.
  •  Speak briefly.
  •  Encourage spontaneity, expression of feelings.
  • If the client is hyperverbal, ask closed-ended questions.

C. Assist client to clarify feelings and events and place them in time sequence.

  •  Focus on emotionally charged area(s).
  •  Maintain accepting, nonjudgmental attitude.

D. Give broad openings and ask open-ended questions to enable client to describe what is happening with him or her.
E. Use body language to convey empathy, interest, and encouragement to facilitate communication.
F. Use silence as a therapeutic tool; it enables client to pace and direct his or her own communications. Long periods of silence, however, may increase client’s anxiety level and should be avoided.
G. Define the limits of the interview: Determine the purpose and structure the time and interaction patterns accordingly.
H. Never employ interviewing techniques as stereotyped responses during an interview.

  •  Use of such responses negates open and honest communication.
  •  Use of structured responses is counterproductive, as it presents nurse as a nonempathic communicator.
  •  Interaction must be alive and responsive, not dependent on a technique for continuance.
  •  Use “I” messages rather than “you” messages. (For example, “I feel uncomfortable,” not “You make me feel uncomfortable.”)

I. Watch for transference reaction from client (unconscious process of attributing feelings toward the nurse that originally belonged to a significant person in client’s previous experience).
J. Assist client to build more effective coping mechanisms.

  • Gather pertinent data.
  • Define the problem.
  • Mutually agree on working toward a solution.
  • Mutually set goals.
  •  Select alternatives.
  •  Activate problem-solving behavior for identified problems.

Psychiatric Nursing: Anxiety

Focus topic: Psychiatric Nursing

Definition: Anxiety is an affective response subjectively experienced as a response to an internal or external threat, real or imagined, known or unknown. It is experienced as a painful, vague uneasiness or diffuse apprehension, or focused such as chest pain. It is a form of energy whose presence is inferred from its effect on attention, behavior, learning, and perception. Anxiety is considered pathological if it interferes significantly with functioning or is striking in its lack of proportion to a situation.

Characteristics
A. Anxiety is perceived subjectively by the conscious mind of the person experiencing it.
B. Anxiety is a result of conflicts between the personality and the environment or between different forces within the personality or physiological imbalances.
C. Anxiety may be a reaction to threats of deprivation from something biologically or emotionally vital to the person.
D. The causative conflicts and/or threats may or may not be in the awareness or in the conscious mind of the person.
E. The amount or level of anxiety is related to the following factors:

  •  Degree of threat to the self.
  •  Degree to which behavior reduces anxiety.

F. Varying degrees of anxiety are common to all human beings at one time or another.
G. Anxiety is often found in mental health disorders.
H. Anxiety is easily transmitted from one individual to another.
I. Constructive use of low-to-moderate levels of anxiety is healthy; it is often an incentive for growth.
J. The more capacity to manage anxiety, the more control an individual has over his or her environment.

Psychiatric Nursing

K. Anxiety may be acute (precipitated by an event or threat) or chronic (caused by various sources) present for a long period of time.
L. Disturbances in neurotransmitters/neurochemistry, brain anatomy, and endocrine systems are some causes implicated in pathophysiology.
M. Medical conditions may cause or contribute to worsening of anxiety.

Assessment
A. A major assessment criterion for measuring the degree of anxiety is the person’s ability to focus on what is happening to him or her in a situation.
B. Assess physiological, familial, environmental, and situational contributions to anxiety.
C. Physiological reaction(s) present in client.

  •  Increased heart rate, palpitations, chest pain.
  •  Increased or decreased appetite.
  •  Hyperventilation, dyspnea.
  •  Tendency to void and defecate.
  •  Dry mouth.
  •  Butterflies in stomach, nausea, vomiting, cramps, diarrhea.
  •  “Fight or flight” response, restlessness.
  •  Tremors.
  •  Dizziness, lightheadedness.
  •  Numbness of extremities.
  •  Perspiration.

D. Psychological reactions present in client.

  •  Lack of concentration on work.
  • Feelings of depression and guilt.
  •  Harbored fear of sudden death, mental illness, or loss of control.
  •  Dread of being alone.
  •  Confusion.
  • Tension.
  •  Agitation and restlessness.

E. States of anxiety vary in degree and can be assessed as follows:

  •  Ataraxia (absence of anxiety).
    a. State is uncommon.
    b. Can be seen in persons who take drugs.
    c. Indicates low motivation.
    (1) Mild.
    (a) Senses are alert.
    (b) Attentiveness is increased.
    (c) Motivation is increased.
    (2) Moderate.
    (a) Peripheral field is narrowed, attention is selective, ability to concentrate is diminished.
    (b) Degree of pathology depends on the individual.
    (c) May be detected in complaining, arguing, teasing behaviors.
    (d) Can be converted to physical symptoms such as headaches, low back pain, nausea, diarrhea.
    (3) Severe.
    (a) All senses are gravely affected.
    (b) Perceptual field greatly reduced.
    (c) Behavior becomes automatic toward immediate relief.
    (d) Energy is drained.
    (e) Defense mechanisms are used to control severe levels of anxiety.
    (f) Cannot be used constructively by person.
    (g) Psychologically extremely painful.
    (h) Learning and problem solving not possible.
    (i) Nursing action always indicated for this state.
    (4) Panic.
    (a) Individual is overwhelmed and feels helpless.
    (b) Personality may disintegrate producing hallucinations or delusions.
    (c) Wild, desperate, ineffective behavior may be observed, including sense of awe, dread, terror, uncanniness, and impulsivity.
    (d) Detail previously focused on is exaggerated.
    (e) Client may do bodily harm to self and others, accidentally or intentionally.
    (f) Panic state cannot be tolerated very long.
    (g) Condition is pathological.
    (h) Immediate intervention is needed.

Implementation
A. Identify anxious behavior and the level of anxiety that determines degree of intervention.
B. Remain with an anxious client.
C. Recognize anxiety in self may escalate client’s anxiety.

D. Maintain appropriate attitudes toward client.

  • Acceptance.
  •  Calm, matter-of-fact, nonthreatening, succinct approach.
  •  Willingness to listen and help.
  • Provide simple, clear instructions and explanations.
  •  Emotional support.

E. Recognize if additional help is required for intervention.
F. Provide activities that decrease anxiety and provide an outlet for energy.
G. Establish person-to-person relationship.

  •  Allow client to express his or her feelings.
  •  Proceed at client’s pace.
  •  Avoid forcing client to verbalize feelings.
  •  Assist client in identifying anxiety.

Assist client in learning new ways of dealing with anxiety.
H. Provide appropriate physical environment.

  • Non-stimulating.
  •  Structured
  •  Designed to prevent physical exhaustion or self-harm or harm to others.

I. Administer medication as directed and needed.

Psychiatric Nursing: Defense Mechanisms

Focus topic: Psychiatric Nursing

Definition: Defense mechanisms are automatic, psychological processes caused by internal or external perceived dangers or stressors that threaten self-esteem and disrupt ego function.

Characteristics
A. The purpose of defense mechanisms is to attempt to reduce anxiety and to reestablish equilibrium.
B. Adjustment depends on one’s ability to vary responses so that anxiety is decreased.
C. Use of defense mechanisms may be a conscious process but usually takes place at the unconscious level.
D. Defense mechanisms are compromise solutions and include those listed in Table 14-4.
E. Defenses may be pathological as well as adaptive.
F. Physiological imbalances may play a role in defense mechanisms a client is utilizing.

Assessment
A. Assess whether client evidences healthy adjustment in the way he or she uses defense mechanisms.

  • 1. Healthy adjustment is characterized by
    a. Infrequent use of defense mechanisms.
    b. Ability to form new responses.
    c. Ability to change the external environment.
    d. Ability to modify one’s needs.
    e. Use of defense mechanisms to lower anxiety to achieve goals in acceptable ways.

B. Assess whether client evidences unhealthy adjustment in the way he or she uses defense mechanisms.

  • Unhealthy adjustment is characterized by
    a. Undeveloped ability or loss of ability to vary responses.
    b. Retreat from the problem or reality.
    c. Frequent use of defense mechanisms, which may interfere with maintenance of self-image and interfere with individual growth and interpersonal satisfaction.
  • Unhealthy adjustment patterns may include mechanisms such as regression, repression, denial, projection, and dissociation.

Implementation
A. Facilitate more appropriate use of defense mechanisms.
B. Remember that defense mechanisms serve a purpose and cannot be arbitrarily eliminated without being replaced by more adaptive coping mechanisms.
C. Avoid criticizing client’s behavior and use of defense mechanisms.
D. Help client explore the underlying source of the anxiety that gives rise to an unhealthy response.
E. Assist the client in learning new or alternative coping mechanisms for healthier adaptation.
F. Use techniques to alleviate client’s anxiety.
G. Use a firm supportive approach to explore any maladaptive use of defense mechanisms.

Resilience
A. SAMHSA definition of resilience: “ability to adapt well over time to life changing situations and stressful conditions. Caring and supportive relationships can help enhance resilience” (Search Institute, 2015).
B. Prevention of childhood trauma (psychological, violence, neglect) supports development of resilience.
C. Personal qualities associated with resilience

  •  Ability to make and implement realistic plans.
  •  Positive, confident outlook.
  •  Ability to communicate and solve problems.

Psychiatric Nursing: DEFENSE MECHANISMS

Focus topic: Psychiatric Nursing

Psychiatric Nursing
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