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Chapter 1: Through the Door Your First Day in Psychiatric Nursing
is mentally healthy when a person possesses knowledge of oneself; meets one’s basic needs; assumes responsibility for one’s behavior and for self-growth; has learned to integrate thoughts, feelings, and actions; and can resolve conflicts successfully.
healthy person maintains relationships, communicates directly with others, and respects others.
healthy person adapts to change in one’s environment.
mentally ill show deficits in functioning; it is usually these deficits that bring them to the facilities where you will encounter them.
illness occurs when an individual is not able to view oneself clearly or has a distorted view of self, is unable to maintain satisfying personal relationships, and is unable to adapt to one’s environment.
Psychiatric Association defines mental disorder as “clinically significant behavior or psychological syndrome or pattern that occurs in an individual and is associated with present distress (i.e., negative response to stimuli that are perceived as threatening) or disability (i.e., impairment increased risk of suffering, death, pain, disability, or an important loss of freedom). See p. 5 for possible signs of mental illness.
Chapter 2: Psychiatric Nursing Evolution of a Specialty Care of the Mentally Ill
Early Civilization The insane were treated through magical rituals, prayer, and exorcism. The Greek and Roman cultures developed ideas of body “humors” – blood, black bile, yellow bile, and phlegm-which could influence emotional stability. Hippocrates believed that excesses of black bile caused melancholy and that bloodletting could remove this excess. Middle Ages and Renaissance The term “lunatic” emerged to refer to one controlled by the lunar body. Treatment of the mentally ill was influenced by beliefs that the mentally ill were evil, witches, or heretics. The mentally ill were excluded from community life or institutionalized. Care was custodial and were poorly fed and clothed and were restrained.
Eighteenth and Early Nineteenth Centuries The mentally ill were committed to asylums. They were place in prison if they committed a crime. Their care was performed by persons without training or interest in helping others and was often lacking in compassion. A few physicians in the U.S. and England began to view the insane as persons suffering disease and needing some kind of treatment. English physician William Battie’s word elevated mental services to something respectable physicians could do. He also believed that the care of the mentally ill should be done by carefully selected and trained. Insanity was viewed as a disease. Physicians began to classify mental disorders. They described moral and physical causes of mental illness. In 1846, the term psychiatry was introduced by physicians and they published their work in The Journal of Mental Science.
Asylums were built for the treatment and cure of the insane.
Nineteenth Century Conditions in the asylums became unbearable. There was a called for reform. Dorothea Lynde Dix became a leader for reform. She advocated for humane treatment as well as safe and comfortable environments for the patient. Through her efforts, care was improved in the U.S., Canada, and Scotland.
and Nineteenth Centuries In 1882, the McLean Asylum in Somerville, Massachusetts, opened the first training school in the world for mental health nurses. Edward Cowles, the physician superintendent of McLean, believed that the presence of a “nurse” indicated not only that the patient was ill but also that there was a hope of recovery. Other schools were opened: Bellevue Training School in New York Connecticut Training School in New Haven These schools operated under the Nightingale model.
The year 1893 marked the first meeting of organized nursing in the U. S. Important Nurse Leaders included: - Isabel Hampton and - Lavinia Dock.
Mental health nurses continued to be trained at asylums and their training evolved to keep up with new approaches in psychiatric care. Twentieth Century The American Psychiatric Association established a committee on Training Schools for Nurses. Johns Hopkins Hospital School included psychiatric nursing in the training of general nurses. This was the first time a hospital program offered training in psychiatric care to all students. By 1920, the first psychiatric nursing textbook was publish, Nursing Mental Disease by Harriet Bailey. In the 1930s, somatic therapies emerged.
In 1946, the U.S. Congress passed the National Mental Health Act, which established the National Institutes of Mental Health. See Table 2-2 for additional important events and trends in psychiatric nursing history.
Psychiatric Mental Health Nurse Psychiatric Mental Health Advanced Practice Registered Nurse (APRN) see [/ 19
Psychiatric Mental Health Nursing’s Phenomena of Concern Community-Based Roles in Psychiatric Nursing (p. 20)
Chapter 3: Theory as a Basis for Practice
is a practice discipline in which the practice is derived from theory that has been developed through or tested by research. Nursing theory may guide and inform specific steps of the nursing process in psychiatric care or may supply a general approach to providing care.
nursing as a therapeutic interpersonal relationship that provides a growth opportunity for both the nurse and the patient. Described a four distinct phases of a interpersonal relationship: Orientation, identification, exploitation, and resolution.
1997, Peplau combined identification exploitation into the working phase, and renamed resolution, termination. Orientation Working Termination
between nursing and medicine by stating that curing is the domain of medicine and caring is the domain of nursing. Proposed 10 carative factors that are involved in forming a humanistic, altruistic system of values; instilling faith-hope; cultivating sensitivity to one’s self and to others; developing helping-trust relationships; expressing positive and negative feelings; using scientific problem-solving methods for decision making; promoting interpersonal teaching-learning; providing an environment that supports, protects, and corrects mental, physical, sociocultural, and spiritual aspects; assisting with the gratification of human needs; and allowing for existential-phenomentological forces (see p. 30)
Proposed a general self-care deficit theory of nursing. Has three constitute theories –self-care, self-care deficit,
and nursing systems which
are based on six central and one peripheral concept. Self-care Self-care agency Therapeutic self-care demand Self-care deficit Nursing agency Nursing system
Chapter 4: Neuroscience as a Basis for Practice
phenomena are somehow caused by an array of biochemical and neurophysiological processes that take place from moment to moment.
Functions of the Brain Monitor changes in the external world Monitory the composition of the body fluids Regulate the contractions of the skeletal muscles Regulate the internal organs Initiate and regulate the basic drives: hunger, thirst, sex, aggressive self-protection Conscious sensation Memory Mood (affect) Thought Regulate sleep cycle Language The Four Major Divisions of the Central Nervous System Spinal Cord Brain Stem Diencephalon Cerebral Hemispheres
major functions having to do with consciousness can be localized to the diencephalon and cortex (cerebral hemispheres). Neurotransmitters is a chemical substance that functions as a neuromessenger.
muscle movement Integration of emotions and thoughts Involved with decision making Stimulates hypothalmus to release hormones (sex, thyroid, adrenals)
disorders such schizophrenia is associated dopamine. This may be due either to excess release of transmitter or to increased receptor responsiveness.
in brain affects mood sympathetic branch of ANS for “fight or flight”
a role in sleep regulation, hunger, mood states, and pain perception a role in aggression and sexual behavior The most commonly group is the selective Serotonin Reuptake Inhibitors.
include Prozac, Zoloft, and Paxil.
a role in learning, memory regulator’ manic, sexual aggression Plays a role in modulating neuronal excitability and anxiety Stimulates parasympathetic nervous system
to exert an inhibitory effect on neurons in many parts of the brain. Drugs that can enhance this effect exert a sedative-hypnotic action of brain function Many drugs with this type of effect tend to reduce anxiety and some are actually used as antianxiety agents. The most commonly used drugs of this group are the benzodiazepines (Dalmane, Halcion, Ativan, Xanax)
response Stimulates gastric secretion
- Consists of two major structures:
– critical structure for maintaining consciousness
– involved in a wide range of regulatory functions, especially those that relate to emotion; exerts control over both the autonomic nervous system and the endocrine system: two systems that affect the way we perceive emotion
Lobes Frontal Temporal – strongly involved with emotion and memory Parietal occipital
in the temporal lobe is a complex set of structure known as the limbic system.
Chapter 5: Diagnostic Systems for Psychiatric Nursing
is a system of categorization that allows useful distinctions to be established, distinctions that may lead to deeper understanding of natural phenomenon.
ICD-9 Consists of a comprehensive listing of clinical diagnoses, each associated with a unique numerical code. Permits computerized data entry and tracking. Are commonly three-digit numbers followed by a decimal point and a single digit (e.g., 296.2 for Major Depressive Disorder – single episode) Used in epidemiological analysis and insurance companies DSM-IV-TR Includes explicit criteria for making psychiatric diagnoses, and these criteria have been increasingly validated by careful epidemiological study. Has a multiaxial system that allows developmental and other disorders to be considered along with psychiatric diagnoses of more recent onset.
are five axes: I identifies clinical disorder Axis II identifies personality disorders and conditions of mental retardation Axis III identifies general medical conditions Axis IV identifies psychosocial and environmental problems
V identifies a global assessment of functioning (see p. 74) NANDA Taxonomy of Nursing Diagnoses Consist of statements of phenomena of concern to nurses and can be used in conjunction with DSM criteria. Permits one to identify client concerns as nursing diagnoses. Can be used as a tool in naming and describing phenomena of concern to all nurses and in all nursing’s specialties.
Nursing Interventions Classification (NIC)
a classification of nursing interventions. used to identify and document those activities that nurses carry out to assist client status or behavior.
Health Insurance Portability and Accountability Act (HIPAA) Addressed privacy of all records, both paper and electronic. Required health care institutions to develop systems for training staff and for implementing privacy protections.
Chapter 6: Tools of Psychiatric Mental Health Nursing
Communication is the key to successful psychiatric – mental healthy nursing. Psychiatric mental health nurses use tools of self and tools of knowledge in their Therapeutic
communication is the purposeful use of dialog to bring about the client’s insight, control of symptoms, and/or healing. To accomplish therapeutic communication, the nurse needs to understanding communication theory and how to build a positive nurse-client relationship. Nonverbal Communication Refers to all of the messages sent by others than verbal or written. Includes behaviors, cues, and presence (such as proximity) that sends a message. Physical Space Denotes a sense of relationship between two people. Has meaning in communication. Public space = approximately 12 feet Social space = 9 to 12 feet Personal space = 18 inches to about 4 feet Intimate space = closer than 18 inches Actions or Kinetics Refer to movements, expressions, question, and posture that accompany interactions and influence communications. NOTE: They are almost always culture-bound.
Paralinguistic Cues Provide the context in which the words are delivered, and they influence meaning directly. Include tone, pitch, emotions expressed verbally (such as anxiety or anger or fear), sounds of hesitation, nervous laughter, and nervous coughing. Must be interpreted within the context of the client’s cultural and social/familial norms. Touch Is a form of communication used almost daily by nurses providing direct physical care and support to clients. Can convey warmth, positive regard, support during silence, and reassurance that the nurse if fully present and caring. Has many meanings (appropriate and inappropriate touching). Verbal Communication Is the use of words, written and spoken, to send messages to another. For communication to be most therapeutic, it must convey a respectful attitude, one that supports the individuality and self-esteem of both the client and the nurse. Therapeutic Communication Techniques Listening Silence Broad Openings Restating Clarification Reflection Focusing Informing Suggesting Confronting Defense Mechanisms Are unconscious responses used by persons to protect themselves from internal conflicts and external stressors.
– Negation of reality of threatening situations, despite factual evidence of one’s own thoughts, feelings, or impulses to others
Projection – Attribution Repression
– Unconscious blocking from awareness material that is threatening or painful. Intellectual explaining away of threatening circumstances.
Rationalization – Introjection –
Incorporating, without examination or thought, the qualities or attitudes
Displacement – Transfer
of feelings or reactions evoked by one topic or event to another that is less threatening. formation – Expression of a feeling that is the opposite of one’s authentic feeling or of feelings that would be appropriate in the situation. – Retreat to a previous developmental level
– Conscious or unconscious attempt to keep threatening material out of consciousness.
Channeling of socially unacceptable impulses into socially acceptable Use of an object, idea, or act to express emotion that is not expressed
directly Chapter 7: Cultural and Ethnic Considerations Cultural is a complex whole, including knowledge, belief, art, moral, law, custom, and any other capabilities and habits acquired by man as a member of society. It comprises every verbal or behavioral system that transmits meaning. It is learned, shared, and ever-changing. It is learned through socialization, shared by all group members, and associated with adaptation to the environment. Cultural Sensitivity The Process of Cultural Competence in the Delivery of Healthcare Services (Campinha-Bacote, 1998, 2003)
elements Cultural desire Cultural awareness Cultural knowledge Cultural skill Cultural encounter
blindness is the attempt to treat all people fairly by ignoring differences and acting as though the differences do not exist. Can be perceived as insensitivity just as readily as are stereotyping and ethnocentrism. Cultural Assessment Giger and Davidhizar (2003) p. 108 Andrews and Boyle (2003) p. 108
Normal vs. Abnormal Behavior What is normal in one culture may not be normal in another. Barriers to Mental Health Care Seeking and Acceptable Care Few minority professionals A one-on-one counseling style in the counselor’s office An emphasis on social-emotion needs rather than on vocational and educational needs The verbal focus which is difficult for those with nonstandard English or an accent Monocultural assumptions of mental health Negative stereotypes of pathology for minority lifestyles Ineffective, inappropriate, and antagonistic counseling approaches to the values held by minorities Cultural facilitator or broker vs. a language interpreter Eye contact (Space and Distance) Touch Silence Social Behavior Time orientation
Chapter 10 : Self-care for the Nurse
occurs when caregivers find themselves unable to provide the quality of care that is desirable.
attitude Give up the victim consciousness Be alert and empowered Taking care of your body, mind and spirit Techniques for Healthy Living Relaxation through Medication Exercise Self-hypnosis Energy Balancing/Centering Humor Support Groups
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