Standards of Practice for Psychiatric-Mental Health Nursing: Standard 1: Assessment Practice Standards for Psychiatric-Mental Health Nursing: Standard 2: Diagnosis. Standards of Practice for Psychiatric-Mental Health Nursing: Standard 3: Outcomes Identification Standards of Practice for Psychiatric-Mental Health Nursing: Standard 4: Planning.
Trauma Interventions
Interventions for Special Populations
Other Intervention Modalities
Copyright
Dedication
Acknowledgments
Contributor List
Kathleen Sekula, PhD, PMHCNS, FAAN, Professor, Coordinator: Forensic Graduate Programs, Duquesne University School of Nursing, Pittsburgh, Pennsylvania Programs, Duquesne University School of Nursing, Pittsburgh, Pennsylvania. Hennepin County Medical Center Inpatient Provider, Minneapolis, Minnesota Associated Clinic of Psychology Outpatient Provider, Minneapolis, Minnesota University of North Dakota PMHNP Program Director, Grand Forks, North Dakota Duquesne University Adjunct Faculty, Pittsburgh, Pennsylvania.
Reviewers
To the Instructor
Content New to this Edition
Organization of the Text
Teaching and Learning Resources
To the Student
Reading and Review Tools
Additional Learning Resources
Chapter Features
OUTLINE
Mental Health and Mental Illness
OBJECTIVES
KEY TERMS AND CONCEPTS
Since the days of nervous breakdowns, we have come a long way in recognizing and treating mental illness. Applying this definition to non-conformists and independent thinkers such as Abraham Lincoln, Mahatma Gandhi and Florence Nightingale could result in a judgment of mental illness.
Mental Health Continuum
I have to admit that sometimes I miss the intensity—the sense of power and creativity—of those manic times. I never miss anything about the depressed times, but of course the strength and creativity did not bear fruit.
Risk and Protective Factors
Individual Attributes and Behaviors
Genetic factors are huge predictors of mental health and are implicated in almost every psychiatric disorder. If your emotional regulation is below average, you may need to master some calming skills.
Social and Economic Circumstances
Again, you can counteract the effects of stress on the body and brain if you relax your muscles. You can get an idea of how good you are at regulating your emotions by taking the Resilience Factor Test in Box 1.1.
Environmental Factors
One approach to distinguishing mental health from mental illness is to consider what a particular culture considers acceptable or unacceptable. A striking example of how cultural change affects the interpretation of mental illness is an old definition of hysteria.
Perceptions of Mental Health and Mental Illness
Although research continued into biological treatments for mental illness, psychological theories dominated and focused on the science of the mind and behavior. A diathesis-stress model – in which diathesis represents biological predisposition and stress represents environmental stress or trauma – is the most accepted explanation for mental illness.
Social Influences on Mental Healthcare
In the late 1800s, the mental health pendulum briefly swung to a biological focus with the "germ theory of disease." Germ theory explained mental illness in the same way that other illnesses were described—that is, that a particular agent in the environment caused them. These theories explained the origins of mental illness as defective psychological processes that could be corrected by increasing personal insight and understanding.
Vignette
The President's New Freedom Commission on Mental Health chaired by Michael Hogan issued its recommendations on mental health care in America in 2003. Data from the US Department of Health and Human Services, The New Freedom Commission of the President on Mental Health.
Legislation and Mental Health Funding
Mental Health Parity
Patient Protection and Affordable Care Act of 2010
Epidemiology of Mental Disorders
Classification of Mental Disorders
A common misconception is that the Classification of Mental Disorders classifies people, whereas the DSM actually classifies disorders. In an increasingly global society, it is important to view the diagnosis and treatment of mental illness in the United States as part of the bigger picture.
Psychiatric-Mental Health Nursing
What Is Psychiatric-Mental Health Nursing?
International Society of Psychiatric-Mental Health Nurses (ISPN)—defines the focus of mental health nursing as "the promotion of mental health through the assessment, diagnosis, and treatment of human responses to mental health problems and psychiatric disorders" (p. 14). The psychiatric-mental health nurse uses the same nursing process you've already learned to assess and diagnose patients' illnesses, identify outcomes, and plan, implement, and evaluate nursing care.
Classification of Nursing Diagnoses, Outcomes, and Interventions
Levels of Psychiatric-Mental Health Clinical Nursing Practice
Currently, the psychiatric-mental health advanced practice registered nurse (PMH-APRN) is a licensed registered nurse with a Master of Science in Nursing (MSN) or Doctor of Nursing Practice (DNP) in psychiatric nursing. Only one examination—Psychiatric-Mental Health Nurse—Board Certified (PMHNP-BC)—is currently available.
Future Issues for Psychiatric-Mental Health Nurses
Educational Challenges
An Aging Population
Cultural Diversity
Science, Technology, and Electronic Healthcare
Scientific advances through research and technology will certainly shape psychiatric-mental health nursing practice. Psychiatric nurses can become more active in developing websites for mental health education, screening, or support, especially to reach geographically isolated areas.
Advocacy and Legislative Involvement
Key Points to Remember
Critical Thinking
Chapter Review
Questions
Mental illness is evaluated solely by taking into account individual control over behavior and assessment of reality. The World Health Organization describes health as “a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity.” Which statement is true regarding overall health.
Answers
Which of the following activities would be considered nursing care and would be appropriate to be performed by an elementary level nurse for a patient with a mental illness? Mental illness changes with culture, time in history, political systems, and the groups that define them.
Theories and Therapies
Dealing with other people is one of the most universally anxiety-inducing activities, and psychological theories provide plausible explanations for complex behavior. This chapter will give you snapshots of some of the most influential psychological theories.
Psychoanalytic Theories and Therapies
Psychoanalytic Theory
During the first few years of life, when the child begins to communicate with others, the ego develops. In the mature and well-adjusted individual, the three personality systems—id, ego, and superego—work together as a team under the administrative leadership of the ego.
Psychodynamic Therapy
For example, if the patient reminds you of someone you don't like, you may unconsciously respond as if the patient were that person.
Interpersonal Theories and Therapies
Interpersonal Theory
Interpersonal Therapy
Implications of Interpersonal Theory to Nursing
Behavioral Theories and Therapies
Classical Conditioning Theory
Behavioral Theory
Operant Conditioning Theory
Another rat was placed in the cage with an electrical charge on the grid under its feet. Teachers use this strategy in the classroom when they ignore acting out behavior that was previously rewarded with more attention.
Behavioral Therapy
In modeling, the therapist provides a role model for specific identified behaviors and the patient learns through imitation. Systematic desensitization is another form of behavior modification therapy that involves developing behavioral tasks tailored to the patient's specific fears; these tasks are presented to the patient while using learned relaxation techniques.
Cognitive Theories and Therapies
Rational-Emotive Therapy
If our beliefs are negative and self-deprecating, we are more susceptible to depression and anxiety. Ellis noted that while we cannot change the past, we can change who we are now.
Cognitive-Behavioral Therapy
Finally, a challenge to negative thinking based on evidence and rational thinking is listed in the last column. Students may overgeneralize ("All psychiatric patients are dangerous.") or personalize ("My patient doesn't seem to be getting better. Maybe I'm not doing well.") the situation.
Humanistic Theories
Theory of Human Motivation
Although Maslow's early work included only five levels of needs, he later took into account two additional factors: (1) cognitive needs (the desire to know and understand) and (2) aesthetic needs (Maslow, 1970). Following Maslow's model as a way to prioritize actions, the nurse meets the patient's physiological need for stable vital signs and pain relief before collecting general information for a nursing database.
![FIG. 2.5 Maslow’s hierarchy of needs. Data from Maslow, A. H. [1972]. The farther reaches of human nature](https://thumb-ap.123doks.com/thumbv2/123dok/10836645.0/91.892.154.783.102.647/maslow-hierarchy-needs-data-maslow-farther-reaches-nature.webp)
Biological Theories and Therapies
Biological Model
In addition to treating psychiatric disorders, they also treat traditional neurological conditions such as Parkinson's disease, epilepsy and pain conditions. Basic nursing strategies such as focusing on the qualities of a therapeutic relationship, understanding the patient's perspective, and communicating in ways that facilitate the patient's recovery occur in addition to physical care.
Developmental Theories
Cognitive Development
Theory of Object Relations
Theories of Moral Development
- Obedience and punishment
- Individualism and exchange
- Good interpersonal relationships
- Maintaining the social order
- Social contract and individual rights
- Universal ethical principles
Listening to authority maintains social order; Bureaucracies and large government agencies often seem to work with this principle. For example, if the social order is corrupt, the rules must be changed and it is a duty to protect the rights of others.
Ethics of Care Theory
But the reasoning behind it is not simply to avoid punishment; it is because the person has begun to take a broader view of society. People at stage 5 still believe that the social order is important, but the social order must be good.
Conclusion
I want to work on this.” Based on this statement, what information should the nurse provide to the patient. Which question should the nurse ask when assessing for what Sullivan's interpersonal theory identifies as the most painful human condition.
Psychobiology and Psychopharmacology
These physiological changes are the targets of the psychotropic (Greek for psyche, or mind, + trepein, to turn) medications used to treat mental illness. Before looking at specific drugs, this chapter begins with an overview of normal functions of the brain and how these functions are carried out.
Structure and Function of the Brain
Functions and Activities of the Brain
If the brain is to achieve vasoconstriction, it must activate the sympathetic nerves to the smooth muscle of the arterioles. All aspects of conscious mental experience and sense of self arise from the activity of the brain.
Cellular Composition of the Brain
Most enzymes start with the name of the neurotransmitter they destroy and end with the suffix –ase. Other neurotransmitters (for example, norepinephrine) are returned to the presynaptic cell from which they were originally released by a process called cellular reuptake.
Organization of the Brain
An example of this method of destruction is the action of the enzyme cholinesterase on the neurotransmitter acetylcholine. Both sensory and motor aspects of language reside in specialized areas of the cerebral cortex.
Visualizing the Brain
In unmedicated patients with schizophrenia, PET scans can show a reduced consumption of glucose in the frontal lobes. Twin studies show lower frontal lobe brain activity in a twin diagnosed with schizophrenia compared to the undiagnosed twin.
Disturbances of Mental Function
The main components in the brain's chemical stew are monoamine neurotransmitters. norepinephrine, dopamine, and serotonin), amino acid neurotransmitters (glutamate and γ-aminobutyric acid [GABA]), neuropeptides (CRH and endorphins), and acetylcholine. First, glutamate activity increases in the hippocampus, then hippocampal metabolism increases, and then the hippocampus begins to atrophy, or shrink the memory center of the brain.
Action of Psychotropic Drugs
Considering Culture
Drug Agonism and Antagonism
Antianxiety and Hypnotic Drugs
The mechanism of action for its sedative effect is most likely due to a strong blockade of the histamine-1 receptor. Although the mechanism of action of buspirone is not clear, one possibility is shown in Fig.
Antidepressant Drugs
The most common side effects are sedation, headache, fatigue, dry mouth, nausea, constipation, dizziness and blurred vision. Like tricyclic antidepressants, many SNRIs have therapeutic effects on neuropathic pain.
Mood Stabilizers
Patients should avoid using some over-the-counter products with sympathomimetic properties (eg, oral decongestants) or serotonergic properties (eg, dextromethorphan). Because of the dangers of inhibiting hepatic and intestinal MAO, patients taking MAOIs should have a list of foods and drugs to avoid.
Anticonvulsant Drugs
Concomitant use with valproate may double the blood levels of lamotrigine and increase the risk of Stevens-Johnson syndrome.
Antipsychotic Drugs
Blockade of the mesolimbic dopamine pathway reduces psychosis, similar to how first-generation antipsychotics work. Clozapine (Clozaril) is an antipsychotic drug that is relatively free of the motor side effects of phenothiazines and other second-generation antipsychotics.
Drug Treatment for Attention-Deficit/Hyperactivity Disorder
The most common side effects of Guanfacine include drowsiness, low blood pressure, nausea, stomach pain, and dizziness. Common side effects include fatigue, irritability, sore throat, insomnia, nightmares, emotional disturbances, constipation, fever, dry mouth, and ear pain.
Drug Treatment for Alzheimer’s Disease
Herbal Treatments
Herbal treatments have been researched to understand their mechanisms of action and have also been used in clinical trials to determine their safety and efficacy. Thus, newer drugs with new mechanisms of action are used in the treatment of schizophrenia, depression and anxiety.
Treatment Settings
Discuss other community-based care providers, including safe community treatment teams (ACT), partial hospitalization programs, and alternative delivery methods of care such as telepsychiatry. Caution would dictate ruling out other causes, such as physical illness, especially because the diagnosis of psychiatric illness is based primarily on symptoms rather than objective measurements such as electrocardiograms (ECGs) and blood counts.
Background
Continuum of Care
Outpatient Care Settings
Primary Care Providers
The practice nurse prescribes fluoxetine (Prozac) 20 mg per day and informs him about his diagnosis and new medication.
Specialized Psychiatric Care Providers
Patient-Centered Medical Homes
Community Mental Health Centers
Psychiatric Home Care
She visits patients who live within a 50-mile radius of her home and has daily telephone contact with her supervisor. He denies suicidal ideation, plan or intent and has been following his anti-depressant regimen.
Assertive Community Treatment
Intensive Outpatient Programs and Partial Hospitalization Programs
Other Outpatient Venues for Psychiatric Care
Emergency Care
Evidence-Based Practice
More psychiatric patients (23%) compared to medical patients (10%) stayed in the emergency room for more than 6 hours. More psychiatric patients (7%) compared with medical patients (2.3%) stayed in the emergency room for more than 12 hours.
Prevention in Outpatient Care
Primary Prevention
Secondary Prevention
Tertiary Prevention
Outpatient Psychiatric Nursing Care
Promoting Recovery and Continuation of Treatment
Inpatient Care Settings
Crisis Stabilization/Observation Units
General Hospital and Private Hospital
State Hospital
Considerations for Inpatient Care
Entry to Acute Inpatient Care
Rights of the Hospitalized Patient
Teamwork and Collaboration
Ultimately, the treatment plan will guide the patient's care during the hospital stay. Input from the patient and family (if available and desirable) is critical in formulating goals.
Therapeutic Milieu
Social Workers: Entry-level social workers help the patient prepare a support system that will promote mental health upon discharge from the hospital. It is important to protect the patient, but equally important is the safety of the staff and other patients.
Unit Design
The Joint Commission, an agency that accredits hospitals, developed National Patient Safety Goals (2015) specific to specialty areas within hospitals to promote patient safety. Doors that open instead of going in to prevent patients from barricading themselves in their rooms.
Inpatient Psychiatric Nursing Care
Specialty Treatment Settings
Pediatric Psychiatric Care
Geriatric Psychiatric Care
Veterans Administration Centers
Alcohol and Drug Use Disorder Treatment
Community mental health centers offer a wide range of mental health services to people who lack funding for care. American Nurses Association, American Psychiatric Nurses Association & International Society of Psychiatric-Mental Health Nurses.
Cultural Implications
This chapter focuses on culture and how it affects the mental health and care of patients with. Variations in cultural beliefs, values and practices affecting mental health and care for patients with mental health problems.
Minority Status, Race, Ethnicity, and Culture
Minority Status
Race
Ethnicity
Culture
Measuring Race and Ethnicity in the United States
European Americans are a diverse group, some of whom have been in the United States for hundreds of years and some of whom are recent immigrants. People from the Middle East and the Arab subcontinent are considered white in the classification system.
Demographic Shifts in the United States
Basic Worldviews
Western Tradition
Eastern Tradition
Indigenous Culture
The holism of body-mind-spirit can be so complete that there may not be sufficient words in the language to describe them as separate entities. Worldviews shape how cultures perceive reality, the person, and the person in relation to the world and to others.
Impact of Culture
A culture's worldview, beliefs, values, and practices are transmitted to its members in a process called enculturation. Culture determines which differences are still within the normal range (mentally healthy) and which are outside the range of normal (mentally ill).
Cultural Barriers to Mental Health Services
Communication Barriers
For example, the expressions feeling blue or feeling down can have any meaning in the patient's literal understanding of English. In addition to interpreters, translators can be crucial in healthcare, as a translation error can be a matter of life and death.
Stigma of Mental Illness
Particularly important in psychiatric settings, interpreters should not be relatives or friends of the patient. Also, those close to the patient may not have the language skills necessary to meet the requirements of interpretation, which is a complex task.
Misdiagnosis
A professional interpreter should match the patient as closely as possible in terms of sex, age, social status and religion. The literal translations of words in one language can have many different connotations in the other language, and certain concepts are so culturally bound that an adequate translation is difficult.
Cultural Concepts of Distress
Genetic Variation in Pharmacodynamics
Treated by an espiritista (spiritual healer) and by the support of the family and community, who provide help to the patient and consider the patient to call for help in a culturally acceptable way. Believed to be caused by possession of a Jin, an invisible being angry with man.
Populations at Risk for Mental Illness and Inadequate Care
Immigrants
Refugees
Cultural Minorities
People who are poor are subjected to a daily struggle for survival, and this takes a toll on mental health. Bias and discrimination taint the health care system, resulting in further strain on the mental health of minority people rather than providing them with the help they need.
Culturally Competent Care
Cultural Awareness
Cultural Knowledge
Family roles and psychosocial norms such as the way decisions are made and the degree of independence versus interdependence of family members. Cultural views about mental health and illness, such as the degree of stigma and the nature of.
Cultural Encounters
Nonverbal communication patterns such as the meaning of eye contact, facial expressions, gestures, and touch. Standards of etiquette such as the importance of punctuality, the pace of conversation and the manner in which respect and hospitality are shown.
Cultural Skill
Those that are harmful to the patient's health and well-being from the point of view of Western medicine. You can encourage the patient's use of neutral values and practices, such as folk remedies and healers.
Cultural Desire
When collecting assessment data, you should identify cultural patterns that may support or interfere with the patient's health and recovery process. Incorporating these culture-specific interventions into nursing care is based on the patient's own coping and healing systems.
![FIG. 1.2 Mental health-mental well-being continuum From University of Michigan, “Understanding U.” [2007]](https://thumb-ap.123doks.com/thumbv2/123dok/10836645.0/42.892.165.787.810.1070/fig-mental-health-mental-continuum-university-michigan-understanding.webp)
