Western Tradition

identity found in individuality; mind and body are separate entities; diseases has a cause and treatment is aimed at the cause; time is linear and success in obtained in preparing for the future

Eastern Tradition

Family basis for identity; body-mind-spirit is one entity; time is circular and recurring; born into a fate; disease caused by fluctuations in opposing forces

Indigenous Culture

The culture of those people who have inhabited a country for thousands of years; places significance on place of humans in natural world; basis of identity is the tribe; person is an entity only in relation to others; diseases lack harmony between individual and environment

cultural awareness

Examine beliefs, values, and practices of own culture

cultural knowledge

Learning cultural differences

how does cultural knowledge help nurses

Establish rapport; Ask culturally relevant questions

Ethnocentrism

individuals’ belief that their cultural values and practices are correct and superior to those of others

Cultural imposition

act of enforcing one culture’s values, beliefs, or practices onto another, often undermining the latter’s cultural identity and autonomy

Enculturation

the gradual acquisition of the characteristics and norms of a culture or group by a person, another culture

Psychological theories help us to explain _______

behavior

Psychoanalytic Theory (Freud)

believed that human development proceeds through 5 stages from infancy to adulthood

Psychoanalysis concepts: Transference and countertransference

Transference – unconscious feelings that the patient has toward a healthcare worker that were originally felt in childhood for a significant other. May be positive or negative (this is the patients feelings) Countertransference – unconscious feelings that the healthcare worker has toward the patient

Newer psychoanalytic model

Focuses more on here and now instead of focusing on younger developmental ages; Best candidates are the “worried well”, well-functioning

who would not benefit from psychoanalytic model

Psychosis, severe depression, borderline PD, severe character D/O

interpersonal theory

Human beings are driven by the need for interaction; Loneliness is most painful human condition

Security operations

measures the individual employs to reduce anxiety and enhance security

Self-system

all of the security operations an individual uses to defend against anxiety and ensure self-esteem

goal of interpersonal theory

to reduce or eliminate psychiatric symptoms by improving interpersonal functioning and satisfaction with social relationships

Foundation for Hildegard Peplau’s theory

Nurse helps the patient to make positive changes, Promoted self awareness, Promoted interventions to lower anxiety levels

Behavioral Theories and Therapies

This theory incorporates “Conditioning” = pairing a behavior with a condition that reinforces or diminishes the behavior’s occurrence; best used in phobias, alcoholism, smoking, schizophrenia, mute, and autistic

Modeling therapy

imitation, role playing

Operant conditioning

positive reinforcement to increase desired behavior

Systematic desensitization

exposure to specific fears while using relaxation techniques

Aversion therapy

pairing a negative stimulus with a specific behavior, (best interest of patient, society and does it violate pt rights)

Cognitive Theory

Dynamic interplay between individuals and the environment; Thoughts about the world and our place in it are based on our own unique perspectives, which may or may not be based on reality

Rational-emotive behavior therapy (Ellis)

Aims to eradicate irrational beliefs (I should, I ought, I must); Recognize thoughts that are not accurate

Cognitive-behavioral therapy (Beck)

Test distorted beliefs, challenge negative patterns and change way of thinking; reduce symptoms, patients are taught to challenge their own negative thinking and substitute with a positive, rational thought

Schemas

a persons unique assumptions about themselves, others or the world in general

Automatic Thoughts/Cognitive Distortions

rapid, unthinking responses based on schemas and are usually irrational and lead to false assumptions and misinterpretations

Common Cognitive Distortions

All or Nothing thinking Overgeneralization Labeling Jumping to Conclusions “Should and Must” Statements Emotional reasoning

Maslow’s Hierarchy of Needs

Focused on human need fulfillment, When lower needs are met, higher needs are able to emerge

The Biological Model
(Medical model)

Abnormal behavior is the result of a physical problem; Locates the illness or disease in the body – usually in the limbic system & the receptor sites of the CNS and targets the site of illness using medicines (psychopharmacology), diet, surgery or brain stimulation (ECT)

Psychopharmacology Therapy

discovery of chlorpromazine (antipsychotic), controlled psychosis and convinced people of the critical role of the brain in psych illnesses

Brain Stimulation Therapies

ECT

Cognitive development (Piaget)

cognitive development is a dynamic progression from primitive awareness and simple reflexes to complex thought and responses Sensorimotor stage (birth – 2) Preoperational stage (2-7 years) Concrete operational stage (7-11 years) Formal operational stage (11 to adulthood)

Theory of psychosocial development (Erikson)

Personality continues to develop & evolve through old age and the unsuccessful completion of each stage will affect the progression to the next stage

Theory of object relations

Past relationships influence sense of self and present relationships; “Object” = a significant person

Theory of moral development

Progression from black-and-white thinking to complex decision making Preconventional level – obedience avoids punishment Conventional level – know right from wrong, “rules are rules” Post-conventional level – GOOD social order, actions create justice

Mental Health Concepts

Overall health is not possible without good mental health

Resilience

an inborn trait that is shaped by internal and external factors

Stigma

the belief that the overall person is flawed, socially shunned, disgrace and shame

Diathesis

Biological predisposition

The Diagnostic and Statistical Manual of Mental Disorders (DSM)

Official medical guidelines of the American Psychiatric Association for diagnosing psychiatric disorders

ICD-10

used for billing and reimbursement

Anger

an emotional response to frustrations of desires, a threat to ones needs, or a challenge. Normal emotion that can be positive if processed in healthy ways. Example: channeling anger into art, exercise, etc. can be a motivator to try harder or aid in survival when fighting is the last resort

Aggression

an action or behavior that results in a verbal or physical attack. Aggression is usually used with violence.

Violence

an act that involves the intentional use of physical force and has the potential to result in injury to another person

Comorbidities to Violence/Aggression

Posttraumatic stress disorder (PTSD) Substance abuse disorders Bipolar disorder

Genetics

some individuals are more biologically predisposed to anger than others. Certain infant and child hood environments influence anger

Neurobiological

some neurobiological conditions are associated with anger and aggression. Brain tumors, Alzheimer’s, temporal lobe epilepsy, and TBI to certain parts of the brain result in changes to the brain that can result in increased violence

The limbic system

area of the brain that controls emotion

Neurotransmitters

especially serotonin, dopamine, and GABA, play a vital role in anger and aggression

general assessment of pts experiencing anger

increased demands, irritability, frowning, redness of the face, pacing, twisting of the hands, or clenching of the fists are all physical/behavioral signs of irritation

Psychosocial interventions

reassure patient that you are listening & concerned, acknowledge their needs and state your expectations “I expect that you will stay in control”

De-escalation

calm, controlled, nonthreatening, caring, relaxed posture, respect personal space, eyes on same level as theirs to decrease sense of intimidation and communicate to the patient that you are listening and speaking to them as an equal

Best indicator of aggressive behavior is

a history of violence and impulsivity and a comorbid dx

Milieu conducive to violence

Inexperienced staff, punitive unit structures, over-crowding, inconsistent limit setting and unpredictable environments

When a pt is showing increased s/s of agitation

offer the pt an ordered PRN medication to help calm them

Use of Seclusion and Restraints can be implemented only

when a pt creates a risk of harm to themselves or to others and when less restrictive measures have been proven ineffective

Seclusion

Involuntary confinement alone in a room that the patient is physically prevented from leaving (goal is always safety of the patient and others)

Restraint

Any manual method, physical or mechanical device, material, or equipment that restricts freedom of movement; Only indicated when all other less restrictive interventions have failed

Contraindications for Restraints

Advanced pregnancy Complicated COPD Head or spinal injuries Seizure disorders Morbid obesity Obstructive sleep apnea

Indications for use of Mechanical Restraints

protect and prevent harm

Legal requirements of Mechanical Restraints

MD signature, discontinue use asap

Documentation of Mechanical Restraints

other interventions used, ongoing evaluation, every 15 minutes

Clinical assessments of Mechanical Restraints

mental state at time of restraints, ruled out medical causes for behavior, physical needs, toileting, food, hydration every 15-30 min

Observation of Mechanical Restraints

1:1, ROM, VS, blood flow in hands/feet, friction

Louisiana Laws Regarding Restraints <9 years old

up to one hour

Louisiana Laws Regarding Restraints 9-17

2 hours max

Louisiana Laws Regarding Restraints 18 and older

4 hours max

When releasing a pt from restraints

remove one at a time. Start with foot and then move to arm on opposite side of body

A violent patient is restrained. What is the nurse’s first priority?

Ensure the patient’s safety

Safety Tips

Pts who are violent need much more personal space than those who are not. (1 foot farther away from the length of a person’s leg is a good rule to follow.)

frontal lobe to be involved in violence

mediate purposeful behavior, elaborate thought, and interact with the limbic system dysfunction in impaired judgment, poor decision making, inappropriate conduct, personality changes, and aggressive outburst

limbic system

receives and synthesizes information related to emotion and memory storage and information processing; dysfunction= cues from present stimuli don't match past experiences, emotions and behaviors are affected, episodes of fear, rage, anger, placidity and indiscriminant hypersexuality

hypothalamus

brain's alarm system controls pituitary function; dysfunction= overly responsive to stress provocation, overly stimulating the pituitary

Ethics

the study of philosophical beliefs regarding what is right and wrong in a society

bio-ethics

the study of specific ethical questions that arise in health care

Beneficence

the duty to act to benefit or promote the good of others (spending extra time to help calm an anxious pt)

Autonomy

respecting the rights of others to make their own decisions. (Acknowledging the pt’s right to refuse medications)

Justice

the duty to distribute resources or care equally, regardless of personal attributes

Fidelity- (nonmaleficence)

maintaining loyalty and commitment to the pt and doing no wrong to the pt

Veracity

the duty to communicate truthfully

Ethical dilemma

results when there is a conflict between two or more courses of action, each carrying favorable and unfavorable consequences

The affordable care act (2010)

provides insurance funding for patients whom have diagnosed mental illnesses. (Obama Care) ex. People who suffered from mental disabilities they could not get medicare and the obama care included them into this act

Informal voluntary admission

least restrictive admission type. Similar to any general hospital admission. No formal application is filled out. Is appropriate when the pt does not pose any serious threat of harm to self or others. The pt is free to stay and can leave at any time against medical advice.

Formal voluntary admission

the pt applies in writing for admission to the facility. Fills out formal application. In Louisiana this pt may request to obtain release but has to give the facility 72 hours’ notice

Involuntary admission

a legally binding admission to the facility without the patient’s consent

criteria for Involuntary Admission

the person is severely mentally ill the pt poses a serious threat of harm to self or others the pt is gravely disabled, the pt is in need of tx and the illness is preventing them from seeking out voluntary assistance

Examples of different types of involuntary admissions

OPC, PEC, CEC, Judicial commitment

Patient Rights

quality treatment, refuse treatment, informed consent, legal counsel and the right to go before a judge and petition to be released, and petition for a writ of habeas corpus

Pts can also challenge the hospitalization based on

the least restrictive alternative doctrine

Capacity

a person’s ability to make an informed decision

Discharge procedures:

release from hospitalization depends on the pts admission status

Conditional release

usually requires outpatient treatment for a specified amount of time in order to monitor the pt and determine if they can be compliant on meds and reintegrate into society

Unconditional release

termination of a pt-institution relationship

Release against medical advice (AMA)

if there is a disagreement between the patient and Dr. on whether the hospitalization is necessary and if the patient is not involuntarily committed the pt may be released against medical advice

Confidentiality

an ethical responsibility of health care professionals that prohibits the disclosure of a pts information without the patients formal consent

HIPAA

legally protects the psychiatric pts rights to receive treatment and to have all records kept confidential. Your legal duty is to protect the pts right to privacy

Confidentiality after death

a person’s reputation can be damaged even after death. It is important that you do not divulge a pt’s information after death. You cannot say anything that you could not say when the pt was alive

Duty to Warn

nurse and all other professional have a duty to warn a pts potential victim of potential harm

Reportable Offenses

informing 3rd parties of risk for danger, suspected child abuse, suspected elder abuse, and suspected abuse of the cognitively impaired

Tort law

when a person wrongfully harms another, the injured party can seek money for damages from the responsible party; injury can be to person, property or reputation

Intentional tort

assault, battery, false imprisonment, invasion of privacy, defamation of character

Unintentional tort

negligence, malpractice

Negligence

failure to use ordinary care in any professional or personal situation when you have a duty to do so

Malpractice

type of professional negligence ex. Doing something you are not supposed to do

5 elements required to prove negligence are

duty, breach of duty, cause in fact, proximate cause, damages

Duty to Report

When a nurse suspects that another nurse is impaired at the work place they have a duty to report that nurse to the State Board of Nursing

Job Abandonment

When a nurse is given report to care for patients, that nurse must provide care

Therapeutic Group

any group of people who meet together for personal development and psychotherapeutic growth. Provide efficient methods of addressing the needs of multiple individuals

Universality

a member recognizes for the first time that she is not so different from others, that other people feel the same way or have had similar experiences

Advantages of Group Therapy

Multiple members can be in treatment at the same time, cost effective, Can be a safe setting to learn new ways of relating to other people and to practice new communication skills, and Groups can promote feelings of cohesiveness

Disadvantages of Group Therapy

Members may feel cheated for participation time, Privacy concerns, and not all patients benefit from group therapy

Patient’s NOT 
Fit for Group Therapy

Acutely psychotic, Acutely Manic, Intoxicated

Catharsis

the process of releasing, and thereby providing relief from, strong or repressed emotions

Altruism

Feeling good about yourself from helping others

Planning phase of group therapy

orientation phase of group therapy

working phase of group therapy

termination phase of group therapy

Task roles

Maintenance roles

Individual roles

Cognitive-behavioral for groups

Psychodynamic for groups

Psychoeducational for groups

Systems for groups

Autocratic leader

Democratic leader

Laissez-faire leader

Expected Outcomes of group

Monopolizing member

Demoralizing member

Silent member

Active Listening communication technique

Asking Questions communication technique

Giving Information communication technique

Clarification communication technique

confrontation communication technique

empathizing communication technique

reflection communication technique

summarization communication technique

support communication technique

HEADSSS Assessment

H – Home environment (r/s with parents and siblings) E – Education & employment (school performance) A – Activities (sports, hobbies, peer relationships) D – Drugs, alcohol, tobacco use S – Sexuality (active, safely, contraception) S – Suicide risk or symptoms of depression S – Safety – (feel safe at home or school, wears seatbelt, engages in risky activities, texting/driving)

Language barriers

need for Interpreter or Translator

Assessment nursing process

We need to rule out if anything physical is going on FIRST because we cant differentiate if what they are going is psychological or physical but we can rule out physical

Diagnosis nursing process