Mental Health last minutes notes- week 1 to week 5

Normal and abnormal behaviours Mental health awareness and wellness

Normal: behaviour that is natural, accepted, Working towards mental wellness

regular, or routine
1. Learn to be at peace with self
Criteria to determine abnormality: 2. Understand yourself
3. Set SMART goals
1. Statistical Infrequency
4. Build strong r/s & network
• Trait, thinking, behaviour that is 5. Maintain healthy lifestyle
rare/unusual 6. Good financial Planning
- Strength: Statistical 7. Volunteer for a cause
- Limitation: Not all unusual 8. Coping with insomnia
behaviour is considered 9. Relax
abnormal - Barriers: food, society,
2. Violation of social norms maladaptive cognitive process,
• Behaviour violates social norms no relax
• Uncomfortable/threatened/incompr - Relax technique: physical
ehensible behaviour exercises, creative activities,
• Consider age, gender, context, complete relaxation
situation
3. Persistent maladaptive behaviour Benefit of mental health promotion
• Unable to cope with daily life
• Improve physical health
demands
• > productivity at work/sch/home
• Characteristic: danger to
• > r/s at home
self/others, loss of control,
• < rates of substance abuse
irrationality, violation of social/moral
• < crime and violence
4. Personal distress
• Creates subjective distress Strategies for public health prevention model
Causes of abnormality • Primary
- Lowering rate of cases of
1. Medical/biological
developing disorder
• Genetics
• Secondary
• Brain dysfunction – neurochemical
- Early detection & intervention
imbalance
• Tertiary
• Brain structure
- Advanced recovery & reduction
• Diathesis-Stress-Theory – genetic
of relapse risk
vulnerability + negative
environmental stressor = mental Nurses role:
illness
2. Psychodynamic model (Sigmund Freud) • Goal: promote constructive coping
a. Unresolved conflicts btw Id mechanisms and maximize
(unconscious instinct), Ego adaptive coping responses
(Conscious), Superego (Morals): • Done through
Weak ego/Unchecked Id 1. Psychoeducation
Impulse/Extreme Superego - Individual/group
b. Childhood & unconscious - Illness mx
motivation - Medication adherence
3. Behavioural model - Constructive coping strategies
a) Classical conditioning - repetition - Instil hope
b) Operant conditioning - attention 2. Environmental Change
c) Social learning theory - imitation - Change one’s immediate
4. Cognitive model environment/larger social
• Faulty and irrational cognition – system (CPN)
negative thoughts 3. Social Support
Mental Health last minutes notes- week 1 to week 5

- Church/civic grps 2. Genuiness

- Self-help grp: e.g. the Tapestry 3. Empathy
Project, Silver Ribbon Project 4. Trust
4. Stigma Reduction 5. Rapport
- Discourage adherence to 6. Care & Respect
effective treatment 7. Non-threathening seating arrangement
- Isolate pt & Family 8. Self-awareness
- Low self esteem 9. Professional boundaries
- Limit access to quality
Phases of TNPR:
healthcare & less desirable
treatment setting 1. Pre-orientation
- Negatively affects attitudes of • Before meeting client:
HCP - Research client condition
TNPR - Review charts, mental physical
evaluation, orders, progress
• Basis of all MH nursing treatment notes, prescribed med, lab
• First connection btw client & nurse results
• Professional r/s helps and heals in - Explore self-perception
nature 2. Orientation
• Establish understanding that nurse • First meet up with client
is safe, confidential, reliable & - Self intro
consistent - Know what they want to be
• Therapeutic use of self called
• Establishing clear boundaries - Establish trust & rapport
• Goal-orientated, moving towards - Specifying contract
wellness - Assuring confidentiality (Unless
suicidal/homicidal)
Goals - Discuss termination
1. Facilitate communication of distressing 3. Working
thoughts and feelings • Allow client to safely experience
2. Assist clients in problem solving and increased levels of anxiety and
facilitates activities of daily living recognise dysfunctional responses
3. Help clients examine self-defeating • Promote change
behaviour & test alternatives - Gather further data
4. Promote self-care & independence - Acknowledge feelings & identify
5. Provide education about meds & stressors
symptoms mx - Identify problem-solving skills &
6. Promote recovery self esteem
- Explore adaptive coping
Professional boundaries and roles strategies & promote
behavioural change
• Establishing boundaries and roles
- Provide education abt disorder
- Provide safe space
- Promote symptom mx
• Blurring of boundaries
- Provide med education
- Under-involvement
- Evaluate progress
- Over-involvement
4. Termination
- Boundary violation
• Attachment ends/Upon discharge
• Blurring of roles
- Summary of goals and
- Transference &
objective achieved
countertransference
- Discuss ways for clients to
Elements needed: incorporate new coping
strategies into daily life
1. Effective communication - Discuss client’s plans for future
Mental Health last minutes notes- week 1 to week 5
- Prep client and nurse
emotionally for closure.
Psychopharmacology
Function of brain
• Monitor changes of external world
• Monitor composition of body fluids
• Regulate contractions of skeletal
muscles
• Regular internal organs
• Initiate & regulate basic drives
• Mediate conscious sensation
• Store & retrieve memories
• Regulate mood & emotions
• Think & perform intellectual
functions
• Regulate sleep cycle
• Produce & interpret language
• Process visual & auditory data
Neurons:
• Respond to stimuli
• Conduct electrical impulses
• Release chemicals called
neurotransmitters (NT)
NT:
Activate behavioural patterns & tendencies in
specific areas of the brain
• Adrenaline: Fight or Flight
- High: insomnia
- Low: lack of focus
• Gaba: Calming
- High: Anxiety
- Low: anxiety/depression/mood
disorder/hyperactivity
• Noradrenaline: Concentration
- High: Stress, anxiety,
hyperactivity
- Low: depression with apathy
• Acetylcholine: Learning
• Dopamine: Pleasure
- High: Schizophrenia, psychosis
- Low: Poor memory/addictions,
craving, poor motor
control/tremors
• Glutamate: Memory
- High: Neurotoxicity, stress,
anxiety, insomnia
- Low: fatigue, poor memory
• Serotonin: Mood
- High: Mental confusion
- Low: Depression/low mood
• Endorphins: Euphoria
Psychotropic drugs:
• Capable of affecting mind, emotion,
behaviour
- Work around neuronal synapse
- Produce change in NT release
- Produce changes in receptors
which NT binds
Treat mental Disorders –
combine with individual/grp
psychotherapy
• Types:
1. Anti-depressants
2. Anti-anxiety
3. Anti-psychotics
4. Mood Stabilizing Agents
Antidepressants
• Time course of response
- Symptoms resolve slowly
- Initial responses develop after
1-3 weeks
- Failure when taken 1 month
without success
• Drug selection
- Antidepressants have nearly
equal efficacy
- Differences relate primarily side
effects, drug interactions, and
cost.
TCAs:
• Less frequently used now due to
adverse effects
• Most common adverse effects:
- Sedation
- Orthostatic hypotension
- Anticholinergic effects (Dry
mouth, constipation)
• Most dangerous adverse effect:
- Cardiac toxicity (lethal if
overdose)
SSRIs
• Adverse Effects
- Stimulant properties: cause
insomnia and agitation
- Sexual dysfunction
- Weight gain
Mental Health last minutes notes- week 1 to week 5
- Withdrawal syndrome
 Minimized by slow dosage
tapering
Adverse Effects:
1. Serotonin Syndrome
• High level of serotonin
• Happens when patient takes 2 or
more drugs that affect serotonin
levels.
• Begins 2 - 72 hours after treatment
• Altered mental status
• Incoordination, myoclonus,
hyperreflexia, excessive sweating,
tremor, and fever
• Syndrome resolves spontaneously
after discontinuing the drug
Suicide risk
• Clients should be observed closely
for the following:
- Suicidality
- Worsening mood
- Changes in behavior
• Precautions
- May increase suicidal
tendencies during early
treatment
- Dosing of in-patients should be
directly observed
Anti-Psychotics
• Dosing
- Highly individualized
- Older adult clients require
relatively small doses
• Routes
- Oral (preferred)
- Intramuscular (Depot)
• Depot antipsychotics: Long-acting,
injectable formulations used for the
long-term maintenance therapy of
schizophrenia
Monitor Extra-Pyramidal Side Effects (ESPE)
- Akinesia
- Akathisia
- Dystonia
- Tardive Dyskinesia
- Oculogyric Crisis
- Pseudo Parkinsonism
Monitor for Neuroleptic Malignant Syndrome
(NMS)
- Diaphoresis
- Sudden Hyperpyrexia
- “Lead Pipe Rigidity” – Muscle
Rigidity
- Autonomic Instability -
Fluctuating BP
- Death without treatment
Atypical Anti-Psychotics (2nd gen)
Examples and Adverse Effects:
• Clozapine, Olanzapine, Quetiapine:
- Sedation, weight gain,
hyperglycaemia and
dyslipidaemia
• Clozapine: Risk of agranulocytosis
(to perform periodic FBC)
• Risperidone:
- Higher risk of EPSE
- Gynecomastia &
Galactorrhoea, sexual
dysfunction
Drug therapy education:
Promoting Medication Adherence
• Establish good therapeutic
relationship with client
• Encourage family members to
oversee medication for out-patients
• Inform clients and families that
medications must be taken on
regular schedule
• Ensure medication is taken
• Inform clients about side effects
• Reporting of side effects
• Assure clients that medication use
does not lead to addiction
• Use intramuscular depot
preparation for long-term therapy
Legal-ethic aspects
Types of Law:
Statutory Law
• Written law
• By legislative body (SNB)
Mental Health last minutes notes- week 1 to week 5

• Decision to detain & care • Action violates statutes,

- Mental Health Act: to provide harming rights of others or
for the admission, detention, injurious to the public welfare
care & treatment of mentally • Criminal offence
disordered persons in -E.g. if nurse takes $3000 from a client
designated psychiatric without consent.
institutions • If found guilty, can be jailed.
• Decision to protect state • Only the government can initiate the
prosecution.
Common Law
Legal terminologies
• Judge-Made law
• Unwritten law based on legal 1. Torts
precedents - civil wrong that unfairly cause
• Case law > legislation someone to suffer loss or harm.
• No official legal codes - Can result in legal liability.
• Judicial precedent are binding (‘like’ - Crimes maybe torts but the
cases treated same). cause of legal action may not
• More flexible be a crime.
• Laws can be modified if outdated or - Could be due to negligence,
current case is different from the not amounting to criminal
precedent case. negligence
• Handles Civil offences, civil wrong doing a) Intentional: assault/battery
(Tort). b) Unintentional: damage
• Unintentional damage like death, property accidentally
personal injury or property damage. 2. Negligence
- Lack of reasonable conduct &
Civil Law care
• Delas with private relations btw citizens - e.g. damages
- Most of the tort cases due to
• Legislation codes collected in a single
negligence.
book
3. Malpractice
• Main source of law is legislation, passed
- Professional negligence,
down by parliament
misconduct
• Judicial precedent not binding
- Unreasonable lack of skill
• Passive role of judge (only establish
resulting in injury or harm
facts)
- e.g. medication error, fail to
• Less flexible
take vital signs
• For civil offences, the resolution to the
4. Assault & Battery
case doesn’t result in going to jail.
- Assault: unjustifiable threat or
• Involves monetary compensation
attempt to touch or injure client
Types: - Battery: actual touching without
consent e.g. use undue power
1. Contract – breach to restrain.
2. Property law 5. Slander
3. Family law - Defamation of Character
4. Tort – any wrongful act which a victim - Communication is malicious &
may sue false
Criminal Law - Nurses need to be objective
when documenting client’s
• Law that deals with criminal case behaviour
• Offences against the government. E.g.
murder, theft Legal Issues

1. Confidentiality & Rights to Privacy

Mental Health last minutes notes- week 1 to week 5

• Privacy: right to be left alone - Can be sued for false imprisonment if

• Confidentiality: duty to respect client’s deliberately confine client in an
privacy unless harm to self or others unauthorised manner
• Nurses are bound by legal & ethical
Guidelines
duties to keep personal information
private i) For emergency or crisis without
• Medical information will be released consent.
only in life threatening condition ii) Get verbal or written consent from
• Need to record in client’s record, e.g. doctor. (Within 1 hr)
date of disclosure, people disclosed to, iii) Orders must be reviewed 4hrly or
reasons & the information disclosed according to hospital policies
2. Consent iv) Monitor every 10 to 15 mins if
a) Informed Consent: needed
- Recognised that clients have
the rights to accept or reject Psychiatric Admission
treatment 1. Voluntary admission
- Protect individual’s autonomy - Voluntary basis can ask for discharge if
- Give sufficient information to ready.
allow client to make an - Mentally competent
informed decision about 2. Involuntary commitment
proposed treatment a) Danger to self or other
- Need to determine if client is  Serious mental illness
competent Need protection from harm to oneself
b) No need for informed consent if: & to other
i) Mentally incompetent & yet b) Observation & treatment
treatment is deemed Forensic, awaiting trial
necessary c) Need treatment and care
ii) Life threatening, harm to Serious mental illness
self & others Gravely disabled & not able to take
(emergencies) care of basic ADL
iii) Crisis situation & client has Reduce suffering & give appropriate
impaired judgement care
c) Nurse act as advocate - Form 1: up to 72h
d) Must be fully aware of the legal Assess a dangerous situation
basis & implication Empowers the psychiatrist to detain
3 major elements - Form 2: another 1mth
Examines by another psychiatrist
i) Knowledge - Form 3: up to 6 mth
- Client must have adequate Examines by another psychiatrist
information
ii) Competency Mental health assessments
- Ensure individual’s cognition is Factors influencing MHA
not impaired
iii) Free will - Biological
- Ensure individual not coerced • Neurochemical imbalance
• Drug effects
Restraints and Seclusion
• Physical impairment
Never used for punishments or convenience - Psychological
• Trauma
Focus on least restrictive intervention • Negative beliefs
Legal implication • Personality traits
- Social
• Language barrier
Mental Health last minutes notes- week 1 to week 5

• Social relationships Milieu therapy

Results of the influences Based on 7 basic assumptions by skinner

(1979)
- Inaccurate assessment
- Uncooperative pt 1. The health in each individual is to be
- Unable to establish trust realized and encouraged to grow
2. Every interaction is an opportunity for
Conducting MHA therapeutic intervention
- Prep environment 3. The client owns his or her environment
• Comfortable 4. Each client owns his or her own
• Privacy behavior
• Reduce environmental stimuli 5. Peer pressure is a useful and powerful
• Ensure safety of patient and tool
others around 6. Inappropriate behaviors are dealt with
• Avoid isolated areas as they occur
- Hx taking 7. Restrictions and punishment are to be
• Behaviour & Emotional state avoided
• Separate sessions for family & Goals
patient
• Sources of information - Manipulate environment to therapeutic
i. Pt for client's experience
ii. Sig. others - Help client learn adaptive coping,
iii. Pt records positive interaction and relationship
iv. Legal & social system skills that can be adapted in other
v. HC professionals aspects of his/her life
- Phrase Qn
8 conditions that promote a therapeutic milieu
• Use open ended questions
• Allows patient to begin 1. Basic physiological needs are fulfilled
• Allows nurse to deter patient’s • In order to move to higher level
perception of functioning (Food, air,
exercised, shelter, water, sleep,
MHA assessment tool
elimination, sexual expression)
1. Health perception health MGT 2. Providing physical, psychological &
2. Cognitive perceptual emotional safety
3. Psycho-social assessment role-r/s - Physical
4. Coping stress tolerance • Conduct Body Check
5. Self-perception & self concept • Remove Potentially Harmful
6. (to 11) Sexuality & Reproductive / Items
Value-Belief / Nutritional-Metabolic / • 24 Hours Observation
Elimination / Activity-exercise/ Sleep • Limit Setting:
• (set rules and norms /
A expectation, explain
B consequences of negative
behaviour, maintain
C consistency)
• Crisis Management (seclusion,
T
restraints, administering of
^ From Tut^ medications)
- Psychological
• Keep client Informed
• Allow Exploration of Painful
Emotions
Mental Health last minutes notes- week 1 to week 5
• Adjunctive Therapies (Art and
Music)
- Emotional
• Provide Assurance and
Comfort
• Establish Trust through
Genuineness, Openness and
Providing Emotional Security
• Provision of Physical Care
3. Conductive physical facilities to achieve
goals of therapy
- Physical space
• Ensure privacy
• Therapeutic communication
with others
• Comfortable and non-
threatening physical
environment to facilitate
interaction and communication
4. A Democratic form of Self-Government
Exist
• Participate in decision-making
and problem solving
• Through regular community
meetings (by staff and clients)
• Equal input in the discussions
of:
 norms rules and
behavioural limits e.g.
No entering of room
occupied by opposite
gender
 consequences of
violating the rules
• Democratic decision made by
the entire group
• Meetings also address conflicts
and questions e.g. Designated
hours of TV programme /
telephone usage
5. Balanced Approach in Client Mx
Nurses role:
• Provide assistance
• When client unable to act on
own behalf
• Accurate judgement about
client's readiness
• Take responsibility
• Gradually allow independent
behaviours
6. Responsibilities are Assigned According
to Client Capabilities
7. A structural program of social and work
related activities
8. Community and family are included in
the program of therapy
- To involve family
• Family Visits
• Family Sessions
• Home Leave
- Involve community through activities
• Shopping
• Field trips
- Community support services
• SOS Helplines, Support
Groups, GPs and Polyclinics
Addictive disorder
Addiction: a chronic, relapsing brain disease
that is characterized by compulsive drug
seeking and use, despite harmful consequences
Types of substance-related disorders
- Alcohol Use Disorder*
- Opioid Use Disorder*
- Tobacco Use Disorder*
- Sedative, Hypnotic, or Anxiolytic Use
Disorder
- Amphetamine Use Disorder
- Inhalant Use Disorder
- Cannabis Use Disorder
Non-substance-related disorders/behavioural
addiction
- Gambling
- Internet
Predisposing factors of substance-related
disorder
- Biological
• Genetics account for 50%-75%
of the risk for developing
substance use disorder
- Psychological
Mental Health last minutes notes- week 1 to week 5
• Existing mental health condition
like anxiety or depression
• Individual who already has
addiction like gambling, food,
or pornography
• People who struggle with
impulse control and thrill
seeking
- Social
• Low income group,
unemployed.
• People who begin drinking
alcohol or using drugs earlier in
life
Terms and definitions
Abuse
- Continuation of use/behaviour despite
evidence of damage to physical/mental
health/socio-occupational
functioning/well-being of family
- Develop into dependence
Dependence
- Layman’s term of ‘Addiction’
- Pattern of compulsive use/behaviour
significant impairment of functional
status
- Dependence include:
• Physical dependence (physical
adaptations to chronic regular
use)
• Psychological dependence
(behavioural adaptations)
Withdrawal
- Abstinence leads to features of
withdrawal
- Symptoms are often the ‘opposite’ of
the acute effects
Alcohol use disorder: (AUD)
DSM-5 diagnostic criteria
- Impaired control
• Use large period of time than
intended
• Use large amount than
intended
• Unsuccessful efforts to cut
down
• Spend excessive time getting
the substance
• Intense craving
- Social Impairment
• Continue to use substance
despite problems at
work/school/family
• Repeated work absences, poor
school performance, neglect
family, fights with family
• Can’t meet household
responsibilities
• Lose important friendships
• Give up social & recreational
activities
- Tolerance
• Occurs when need to increase
the amount of substance to
achieve the desired effect to
get high
- Withdrawal
• Body’s response to the abrupt
cessation of substance once
the body develop a tolerance to
it
• Unpleasant & can be fatal
- Risk
• Repeatedly use in physically
dangerous situation
DSM-5 Mild AUD diagnosis
- Presence of 2-3 criteria
DSM-5 Moderate AUD Diagnosis
- Presence of 4-5 criteria
DSM-5 Severe AUD Diagnosis
- Presence of 6 or more criteria
Mental Health last minutes notes- week 1 to week 5

Understanding alcohol - Liver Function Test

Blood Alcohol Level (BAL) Treatment & interventions for alcohol use
disorder
0.01% = 10mg/dl
- Early identification, education and
No. of BAL Effects intervention
drinks
- Confidential and non-judgemental
1 0.02-0.03No overt effects, slight
approach
mood elevation
- Evaluate for comorbidities and treat
2 0.05-0.06 Relaxed feeling, slightly
reduced reaction time other disorders
3 0.08-0.09 Impaired balance, - Evaluate own attitude regarding
speech, vision, hearing; substance use/dependence
euphoria, increased - Psychotherapy
confidence; loss of - Behaviour Therapy
motor coordination - 12-Step Programs
4 0.11-0.12 Impaired judgment, - Psychopharmacology
mental executive - Hospitalization
functions
10 0.30 Severe intoxication; Opioid Use Disorder
minimal conscious
DSM-5 Diagnostic criteria
control of mind/body
14 0.40 Coma Clinically significant impairment or distress, as
20 0.60 Death from Respiratory manifested by at least two of the following,
Failure occurring within a 12-month period:
0.08% = 80mg/dl [Legal intoxication limit in SG]
- Opioids are often taken in larger
amounts or over a longer period than
Delirium Tremens was intended.
- Persistent desire or unsuccessful efforts
- MEDICAL EMERGENCY to cut down/control opioid use.
- Acute confusional state due to alcohol - A lot of time spent trying to obtain the
withdrawal opioid, use the opioid, or recover from
- 5% of cases its effects.
- Occurs 1-7 days after last drink - Craving
- Peak incidence at 48 hrs - Recurrent opioid use  in a failure to
- Predisposing factors: severe fulfil major role obligations at work,
dependence, comorbid medical school, or home.
illnesses, pre-existing liver damage - Continued opioid use despite having
- Features: persistent or recurrent social or
• Clouded consciousness interpersonal problems caused or
• Disorientation exacerbated by the effects of opioids.
• Marked agitation - Important social, occupational, or
• Vivid hallucinations – visual and recreational activities are given up or
tactile reduced because of opioid use.
• Paranoid delusions - Recurrent opioid use in situations in
which it is physically hazardous.
Lab/Tests/Exams
- Continued opioid use despite
- Short Michigan Alcohol Screening Test knowledge of having a persistent or
- CAGE Questionnaire recurrent physical or psychological
- AUDIT, Alcohol Screening and Brief problem that is likely to have been
Intervention caused or exacerbated by the
- CIWA substance.
- Toxicology Screening
Mental Health last minutes notes- week 1 to week 5
- Tolerance, as defined by either of the
following:
A need for markedly increased
amounts of opioids to achieve
intoxication or desired effect.
A markedly diminished effect with
continued use of the same amount of an
opioid.
- Withdrawal
Characteristic opioid withdrawal
symptoms
Opioid taken to relieve symptoms
Understanding Opioid
- Common forms
• Heroin, Codeine (Syrup and
Tablets)
• Tramadol, Opium, Methadone,
• Buprenorphine (Subutex)
• Others (Morphine, Fentanyl,
Pethidine)
Short term effect of Heroin
Rush [Pleasure/euphoria]
Other common effects
- Dry mouth
- Warm flushing of the skin
- Heavy feeling in the arms and legs
- Nausea and vomiting
- Severe itching
- Clouded mental functioning
- Going "on the nod," a back-and-forth
state of being conscious and
semiconscious
Long term effects of Heroin
- Insomnia
- Collapsed veins for people who inject
the drug
- Damaged tissue inside the nose for
people who sniff or snort it
- Infection of the heart lining and valves
- Abscesses (swollen tissue filled with
pus)
- Constipation and stomach cramping
- Liver and kidney disease
- Lung complications, including
pneumonia
- Mental disorders such as depression
and antisocial personality disorder
- Sexual dysfunction for men
- Irregular menstrual cycles for women
Heroin withdrawal
- Restlessness
- Severe muscle and bone pain
- Sleep problems
- Diarrhoea and vomiting
- Cold flashes with goose bumps ("cold
turkey")
- Uncontrollable leg movements ("kicking
the habit")
- Severe heroin cravings
Treatment and intervention for opioid use
disorder
- Contingency Management
- Cognitive Behavioural Therapy
- Motivational Enhancement Therapy /
Motivational Interviewing
- Individual Drug Counselling and Skills
Training e.g. social skills, problem
solving, anger management, relaxation
training
- Psychoeducation
- Psychostimulant Medication e.g.
Methylphenidate (MPH), Modafinil
(MOD)
- Antidepressants and other medications
(Bupropion, Mirtazapine, Topiramate,
Naltrexon, Disulfiram)
Tobacco use disorder
Use of tobacco products over one year has
resulted in at least two of the following sub
features:
- Larger quantities of tobacco over a
longer period then intended are
consumed.
- Unsuccessful efforts to quit or reduce
intake of tobacco
- Inordinate amount of time acquiring or
using tobacco products
Mental Health last minutes notes- week 1 to week 5
- Cravings for tobacco
- Failure to attend to responsibilities and
obligations due to tobacco use
- Continued use despite adverse social or
interpersonal consequences
- Forfeiture of social, occupational or
recreational activities in favour of
tobacco use
- Tobacco use in hazardous situations
- Continued use despite awareness of
physical or psychological problems
directly attributed to tobacco use
Tolerance for nicotine as indicated by:
- Need for increasingly larger doses of
nicotine in order to obtain the desired
effect
- Noticeably diminished effect from using
the same amounts of nicotine
Withdrawal symptoms
- The onset of typical nicotine associated
withdrawal symptoms is present
- More nicotine or a substituted drug is
taken to alleviate withdrawal symptoms
Level of severity
- Mild: 2-3 symptoms
- Moderate: 4-5 symptoms
- Severe: 6 or more symptoms
Nicotine withdrawal
- Intense cravings for nicotine
- Tingling in the hands and feet
- Sweating
- Nausea and abdominal cramping
- Constipation and gas
- Headaches
- Coughing
- Sore throat
- Insomnia
- Difficulty concentrating
- Anxiety
- Irritability
- Depression
- Weight gain
Treatment and intervention for tobacco use
disorders
- Smoking Cessation
- Social Support through Smoking
Cessation and Self Help Groups
- Exercise as an Adjunct to Relieve
Nicotine Cravings
- Cognitive Behavioural Therapy (CBT)
- Nicotine Replacement Therapy (NRT)
- Counselling
Substances related disorder
Client/Family education
- Denial is usual defence mechanism
- Approach in a supportive and non-
judgemental manner
- Focus on consequences of continued
substance use and abuse
(Physically/Emotionally/Family/Employm
ent)
- Discuss need for complete abstinence
and treating these disorders
- Seek help through organizations (e.g.
AIAnon or NarAnon and AlaTeen,
Alcoholic Anonymous, Narcotics
Anonymous)
- Use of medications to reduce cravings
Gambling Disorder
DSM-5 Classification criteria
Persistent and recurrent problematic gambling
behaviour leading to clinically significant
impairment or distress, as indicated by the
individual exhibiting four (or more) of the
following in a 12-month period:
- Needs to gamble with increasing
amounts of money in order to achieve
the desired excitement
- Restless/irritable when attempting to cut
down or stop gambling
- Has made repeated unsuccessful
efforts to control, cut back, or stop
gambling
- Is often preoccupied with gambling
- Often gambles when feeling distressed
- After losing money gambling, often
returns another day to get even
(“chasing” one’s losses)
- Lies to conceal the extent of
involvement with gambling
- Has jeopardized or lost a significant
relationship, job, or educational or
career opportunity because of gambling
Mental Health last minutes notes- week 1 to week 5
- Relies on others to provide money to
relieve desperate financial situations
caused by gambling
Types of gambling addiction [SG]
- Casino Gambling
- 4D, Toto, Singapore Sweep
- Sports Betting
- Horse Racing
- Jackpot
- Cruise Ship Gambling
- Mahjong
- Online Gambling
Withdrawal symptoms
- Cravings to Gamble
- Anxiety
- Insomnia
- Depression
• Feeling helpless and hopeless
• Loss of interest in daily
activities
• Changes to sleep patterns
Physical Symptoms of excessive gambling
- Headaches
- Racing heart
- Palpitations
- Muscle tension and/or soreness
- Tightness in the chest
- Tremors
Treatment and intervention for gambling
disorder
- Individual Counselling
- Group Counselling
Community services
WE CARE COMMUNITY SERVICES
- Receive support and treatment
programmes for alcohol & drugs
addiction
- Individual counselling (private &
confidential)
- Family members can join family
workshops & education on how to
support the affected loved ones
- A drop-in center to socialize with other
recovering persons and support each
other through their hardships and
celebrate their victories
NATIONAL ADDICTION MANAGEMENT
SERVICES
- Increase knowledge and understanding
of addiction and develop effective plan
to manage addictions.
- Join group therapy to learn and gain
support from peers who have recovered
or who are recovering.
- Family members can join counselling
program to gain support in caregiving
role and dealing with issues arising from
living together.
- Undergo a two week inpatient
detoxification programme to prevent
complications of withdrawal syndrome.
SINGAPORE A A
- FOC for being a A.A. member
- Only requirement is a desire to stop
drinking
- Read articles submitted by other
members sharing their experience and
strength with hope that they may solve
their common problem and help each
other to recover from alcoholism
- May submit his/her story anonymously
to a Google Drive folder
- Attend a weekly meeting even he/she is
travelling or moving to other countries
as A.A. is worldwide organisation
Depression
Mood
- Pervasive & sustained emotion
Major Depressive Disorder (MDD)
- Most common psychiatric disorder
- Higher among sg adults
- Women>men
- If left untreated – high risk of suicide
MDD Characteristics
1. Physiological Symptoms
• Insomnia, loss of appetite
• Psychomotor agitation or
retardation
2. Emotional Symptoms
• Anger, irritability, sadness,
despair, avolition
Mental Health last minutes notes- week 1 to week 5
Sadness:
• Normal emotional pain
• Time will heal
• Cope with crying, distraction etc
Depression:
• Unable to function normally.
• Affects thinking, emotion & behaviour.
• Persistent (weeks/months)
• Unable to identify triggers
Avolition:
• Loss of Drive to initiate action
• Want to do it but unable to
Laziness:
• Lack of will
• Motivation related
• Has a choice
• Transient
3. Behavioural symptoms
• Impulsive, apathy (lack
reaction) withdrawn
• Indifference to people &
situation
Application to nursing
• Be non-judgemental
• Structured activities
• Motivational strategies
• Create safe milieu
• Constructive coping strategies
4. Cognitive symptoms
• Worthless
• Poor concentration
• Impaired Judgement
• Suicide ideation
MDD DSM-5 Criteria
5 or more in the same 2 week period +
depressed mood + anhedonia:
• Depressed mood
• Loss of interest/pleasure
• Change in weight/appetite
• Insomnia/hypersomnia
• Psychomotor retardation/agitation
• Loss of energy/fatigue
• Worthlessness/guilt
• Impaired concentration/indecisiveness
• Thoughts of death
Dysthymic disorder
Characteristic
- Recurrent depressive symptoms
- Symptoms mainly on depressed mood,
pessimistic outlook, feeling hopeless
- 1-2 years
- Low energy
- ADL affected, functional
impairment
Persistent depressive disorder DSM-5 criteria
(depressed mood most of the day, more days
than not, 2 years or longer)
- Poor appetite/overeating
- Insomnia/hypersomnia
- Low energy/fatigue
- Low self-esteem
- Impaired concentration/indecisiveness
- Hopelessness
- Never without symptoms for more than
2 mths
Mood disorder: Predisposing factors
Biological causes
1. Genetic
• those with parents & siblings
with depression
• Has 2 or 3 times greater risk of
developing depression
• Inherits a unique combination
of genes from parentS
• Certain combinations can
predispose to a particular
illness.
2. Neurochemical Imbalances in the brain
• Low norepinephrine (NE),
serotonin(5-HT) results in low
mood & arousal
• “serotonin hypothesis”
proposes that diminished
activities of 5-HT & NE
pathways is the cause of
depression
3. Neurological Disorder
Mental Health last minutes notes- week 1 to week 5
• Damage of brain especially
frontal lobe
• affects emotional regulation
• resulting from cerebrovascular
accident, Alzheimer’s disease,
brain tumours
4. med side effects
• Medication like Birth control
pills, painkillers, anti-
hypertensive can result in
depression.
5. Hormonal disturbances
a) Thyroid gland
 If underperforming, affects
production of thyroid
hormone
 affecting mood regulation.
b) Adrenal Gland
 If body in stressful state,
too much stress hormones
(cortisol)
 adrenal gland unable to
regulate cortisol
 affects neurochemicals in
brain
 results in low mood
6. Nutritional Deficiencies
 Lack of Vit B6, B12, C, D
 Affects brain functioning &
mood stability
 e.g. ‘Winter blues’
Application to Nursing
- Baseline Hx taking
- Psychoeducation re: compliance to anti-
depressants
- Healthy diet
Psychological Causes
1. Experiencing Losses
 object loss theory
 when experience grief from
losses
 e.g actual losses & symbolic
losses e.g. separated, being
abandoned, loss job
 identifies with the loss person
 losses result in loss of affection
 will experience repressed
anger towards the loss person
results in direct anger towards

self
 this reduce self-esteem
 emotionally vulnerable
 increasing risk of depression.
2. Perceived lack of control
 feel life is not in their control
 numerous failures
 learned to believe that they are
helpless
 learning theory
 cognitive theory
 learnt to believe that things
cannot be changed.
 learned to adopt defeated
attitudes about self &
environment.
 fixed mind set that things
cannot be changed
 learned to remain passive
 Results in giving up &
emotionally depressed
Application to Nursing
- Psychotherapy
• reduce the inner-directed
repressed anger towards self
• heal self-esteem
• re-learn to believe they have
power to change things
- Structured Activities
• help client to refocus negative
mind
• let them feel in control
• reduce anger towards self
• reduce social isolation
• boosting mood
Formulating Nursing Diagnosis
PES format
Problem (P)
Etiology (E)
Symptoms (S): Subjective + Objective
Treatment Modalities
1. Pharmacotherapy
- Anti-depressants
Mental Health last minutes notes- week 1 to week 5
a) SSRIs first line: inhibit reuptake of
serotonin
• citalopram, escitalopram,
fluoxetine, fluvoxamine,
paroxetine, sertraline
b) SNRIs: inhibit reuptake of serotonin
& norepinephrine
• Venlafaxine(Effexor).
Application to Nursing
- Reinforce meds complication & explain
rationale of taking meds
Rationale: SSRI & SNRI
- Correct Neurochemical Imbalances In
The brain
• Increase norepinephrine (NE),
serotonin(5-HT)
• improves mood
2. Psychotherapy
- Teach constructive coping skills
- Encourage expression of feelings
- Learn to challenge own negative or
irrational thoughts
- Explore & learn problem-solving
techniques
- Homework assignments
Rationale: Psychotherapy
- reduce the inner-directed repressed
anger towards self
- heal self-esteem
- re-learn to believe they have power to
change things
3. Electro-convulsive Therapy (ECT)
- Passes a controlled electrical current
through the brain
- Under general anaesthesia
Rationale: ECT
- Electrical stimulation
- correct the neurochemical imbalance in
the brain
- Triggers production of serotonin
- boosts the output of dopamine
- reduce depressive symptoms
4. Repetitive Transcranial Magnetic
Simulation (rTMS)
- Non-invasive
- Use magnetic fields to stimulate nerve
cells in brain
Rationale: rTMS
- Alter neurochemical imbalance in the
brain e.g. serotonin & norepinephrine
- Reduce depressive symptoms.
5. Yoga
- Include controlled breathing exercises,
meditation & relaxation techniques
Rationale: Yoga
- promotes calmness through controlled
breathing
- reduce negative rumination through
deep relaxation & mindfulness
- experience mastery & self-acceptance
- promoting self-esteem
Nursing Intervention
1. TNPR
• Establish therapeutic alliance
• acknowledge feelings,
encourage expression of
feelings
• be empathetic, non -
judgemental
• make them feel secure &
validated
• set mutual goals
Rationale: TNPR
- When client feels accepted &
supported, he/she will trust the nurses.
- fragile self-esteem will be enhanced
- motivated to participate in treatment
programme
- help them open up feelings
2. Create structured, safe milieu
a) Create safe milieu
• monitor suicide risk
• optimise client visibility
• conduct body checks
Mental Health last minutes notes- week 1 to week 5

• remove objects that pose a risk Rationale: Group Psychoeducation

Rationale: No suicide Contract - Provide clients with knowledge &

coping skills
- promote insights - e.g. knowledge that he/she is not alone
• suicide is only sort term - Reduce symptoms of depression &
solution improve well-being
• there are available help - Help them cope

b) create structured milieu 5. Assist self-care needs

• structured activities to divert • Assist or encourage self-care
negative thoughts • e.g. personal care, hygiene,
• refocus their mind grooming & eating
• provides a sense of purpose • Building a habit of self-care
• provides predictability, can build self-esteem
familiarity & control
c) Encourage involvement
• learn constructive coping skills
Nursing Outcomes
• non-threatening learning
environment The client:
• reduce social isolation
• boost mood 1. will not harm self or others.
• reduce depressive symptoms 2. able to apply effective coping strategies
to solve problems.
Rationale: Structured Activities 3. able to express feelings & seek help.
4. sets realistic goals for self.
- Enhance positive mental well-being
5. confident in trying new activities
- More balanced sense of self
- Promotes healthier well-being
e.g. better sleep
- Regulates mood & behaviour
- Provide avenue to express feelings
• e.g. art & music therapy
- Reduce stress levels
- Reduce depressive
symptoms

3. Monitor meds compliance

• Administer anti-depressants as
ordered.
• e.g SSRI or SNRI
• Inform clients that medication
takes 2-3 wks to take effects
• monitor for side-effects
• monitor compliance
4. Organise grp psychoeducation
• Educate clients on
a. mental condition
b. treatment adherence,
c. ways of maintaining
psychosocial functioning
d. relapse prevention