Mental Health Nursing

Me: learning therapeutic communication

Meds: medication skills, understanding reason and side effects for treatment
Milieu: maintaining safe and therapeutic environment for patient

Psychotherapeutic interventions
- Therapy provided by trained nurses
- Communication focused on respect

Psychopharmacology
- Knowledge of psychiatric medications is vital
- PRN meds, drug-drug and drug-food interactions, drug-related complications
- Level of compliance and patient understanding

Therapeutic milieu
- Set limits, create clear expectations for behavior
- Maintain an environment of safety and daily structure by removing hazardous
objects and allowing as much independence as possible
- SAFETY, structure, norms, limit setting, balance
- Ineffective Milieu – excessive stimuli, lack of staff involvement, too much
unstructured time!

Continuum of Care – nurses are managers of care – what services do they need – want
them in LEAST restrictive environment! What is their level of function?

Recidivism – “revolving door” – in and out of the hospital.

Pre-enlightenment period
 Assistance – maintenance of basic care
 Banishment – removed from society, left to die
 Confinement – separated from society, locked in facility
Enlightenment Period
 Asylum definition – “Place of refuge” – fewer stressors, fed them, clothed
them, abolished whips/abuse, but quickly became a place of torment.
 Dorothea Dix – opened 32 state asylums in US. First psych nurse in U.S.
Period of scientific study
 Freud—described human behavior in psychological terms – placed value in
talking about problems/dreams.
 Kraepelin—classified mental disorders
  Bleuler—coined the word schizophrenia and added understanding to the
treatment of this illness
 Mileau Therapy began during this time – wanted to help people and not just
push them aside.
Psychotropic drugs (1950s)
 Chlorpromazine (antipsychotic)
 Imipramine (antidepressant)
 Lithium (mood stabilizer/antimanic)

Period of Community Mental Health

- 1946: President Truman signed the National Mental Health Act, establishing the
National Institute of Mental Health, moving away from asylums and into
community treatment.
- Deinstitutionalization (after 1955) to trans-institutionalization
- Social security and SSI assistance – especially schizophrenia – providing income
while living in the community.
- Problems with this period – not enough treatment centers (rural), many psych
patients burn their bridges (family/support) so they don’t have anywhere to go,
many PCP/NP are not trained to adequately treat.

Hildegard Peplau – first psych nurse theorist who talked about groups.

Legal Issues
- Not guilty by reason of insanity – committed the crime but did not understand
implications and consequences thereof. Will go to psych facility for their sentence.
- Negligence – personal wrongdoing
- Malpractice – professional negligence
- Duty to Warn Others – threatened suicide or harm – must balance protection of
confidentiality with responsibility to warn of possible danger.
- Assault, Battery, False Imprisonment – remember assault is a threat and battery
you intentionally touch them. False imprisonment you restrain or confine.

Commitment –
- Voluntary – seek treatment on their own – sign their own documents – takes 48 to
72 hours to assess and stabilize – can leave AMA.
- Involuntary – “commitment” – patient may have the legal capacity to consent but
refuses to do so. MUST have TWO psychiatrists say they are a danger to
themselves or others for someone to be committed.

Patient Rights –
- Right to Treatment with least Restrictive Environment
- Right to Confidentiality of Records
 - Right to Freedom from Restraints and Seclusion
- Right to Give/Refuse Consent to Treatment **unless court ordered and a danger to
yourself or others**

Cultural
- Four worldviews
 Analytical – time, individuality, possessions. Prefers written, hands-on, visual
resources.
 Relational – spiritually grounded, relationships are significant. Prefers verbal
learning.
 Community – community needs are more important than individual needs.
Quiet and communicate respectfully – enjoy meditation and reading.
 Ecologic – interconnectedness exists b/t humans and earth - responsibility to
take care of the earth. Learning is accomplished through quiet observation and
contemplation – verbal communication is minimized.

Culture-Bound Syndromes – things that are stressors for certain cultures.

- Cultural Language – describing psychotic symptoms in different ways (running
amok, ghost sickness).
- Ethnopharmacology/Alternative Therapy
- Cultural Negotiation – working within the patient’s cultural belief system to
develop culturally appropriate interventions.
- Cultural Repatterning – incorporating cultural preservation and negotiation to
identify patient needs.
- Cultural Assessment – include basic elements like nutrition, family relationships,
health beliefs, education, spiritual beliefs, and biologic/physiologic elements.
- Cultural Preservation – ability to acknowledge, value, and accept a patient’s
cultural beliefs.

DSM-5 is manual of Mental Disorders published by APA.

Etiology – two camps

- Nature – mental disorders arise from organic, biologic, genetic problems

- Nurture – mental disorders arise from psychodynamic, functional, environmental,
early life experiences.

A delusion is a false, fixed belief.

MODELS:
 - Recovery – focuses on improving ability to function, looks at regaining health and
wellness, striving for best potential. Setbacks will occur but are not failures.
Support systems are crucial, noncompliance is positive b/c pt is seen as well
enough to make their own choices.
- Attachment – we are motivated by a need for relationships, a safe emotional
caregiver is crucial even after childhood. If need for comfort is not met, harmful
interactions may occur. Emotional scars can be harder to heal than physical scars –
need to be able to express those emotions without FEAR.
- Developmental – focuses on Erikson – impact of environment, parents, and
society on personality development.
- Interpersonal – is person socially able to live effectively in a relationship – mental
illness is the lack of awareness or skill in relationships – can be a source of
anxiety, maladaptive behaviors and negative personality formation.
- Cognitive Behavioral – focus is on thinking and behaving – goal is to evaluate
distorted or maladaptive thinking – cognitive reframing.

DRUGS

- Agonists – stimulate receptors

- Antagonists – block receptors

Blocking Dopamine in the Tracts –

- Tract 1 – blocks movement and causes EPSEs
- Tract 2 – involved in pituitary function and elevates prolactin level
- Tract 3 – aka mesolimbic – involved in emotional/sensory – relieves hallucinations
and delusions
- Tract 4 – aka mesocortical – involved in cognitive – intensifies negative and
cognitive problems
- Want to BLOCK tract 3 and let tract 4 go.

Reasons for Non-Adherence:

- Lack of knowledge, lack of insight, med reactions in the past, pt feels better, side
effects, complicated dosing, attitudes (meds are a sign of weakness), drug
interactions.

First Generation drugs –

- Haloperidol – high potency – high rate of EPSEs
- Chlorpromazine – low potency – anticholinergic, antiadrenergic SEs

Second Generation drugs –

- Olanzapine – ONLY one with anticholinergic effects
- Risperidone
 - Ziprasidone – LOW risk for ALL
- ALL cause sedation, weight gain, orthostatic hypotension have decreased risk of
EPSEs

Third Generation drugs –

- Aripiprazole –
- Cariprazine
- Both decreased SEs – best group of drugs to try

Test # 2
Antidepressant drugs (KNOW DRUG AND FOOD INTERACTIONS AND
CLASSIFICATIONS)
- Most common type of prescription in US
- Lack of neurotransmitters in intrasynaptic area: serotonin, norepinephrine,
dopamine
- First line SSRIs, second line TCAs, third line MAOIs (strict food restrictions)
- Sertraline, venlafaxine, bupropion
- Issues of antidepressant use
 Serotonin syndrome  hyperthermia, muscle rigidity, hallucinations, ataxia,
muscle twitching
 Occurs if SSRI is combined with MAOIs, cocaine/dextromethorphan
 Antidepressant apathy syndrome  patient losses interest in everything
  Antidepressant withdrawal syndrome  abrupt discontinuation of
 Antidepressant loss of effectiveness  over time, meds stop working
 Antidepressant induced suicide  black box warning in 18-24 years old early
in treatment (still depressed, but enough energy to go through with suicide
plan)
- Side effects of SSRIs
 GI: n/d, loose stools, weight loss/gain
 Anticholinergic effects possible but not as common as in TCAs
 Avoid with narrow-angle glaucoma and hypertrophic prostate syndrome (older
patients)
 CNS effects, libido issues
 Drug interactions
 Increase half life of benzos
- Side effects of TCAs
 More serious than with SSRIs
 Cardiovascular: arrythmias, MIs (avoid with older adults)
 Anticholinergic effects
 CNS: h/a, dizziness, tremors, and sedation
 Drug interactions
 Warfarin: increased bleeding
- MAOIs
 Uncommonly prescribed due to food and drug interactions
 Avoid tyramine rich foods (can cause hypertensive crisis)  alcohol, dairy
products, caffeine

Antimanic drugs
- Bipolar disorder
 15% higher rate of suicide than gen pop
 May sleep 23 hours per day when depressed
 Caused by too much
- Lithium pharmacokinetics, p. 173-174
 0.6 to 1.2, narrow therapeutic range
 No antidote
 Excreted by kidneys, contraindicated in renal disorders
 Acts like sodium in the body
 Maintain normal salt intake and diet
 Dose adjustment with v/d
 Blood draw 8-12 hours after of last dose
 Polyuria and polydipsia occur in 70% of patients
  Weight gain, bloated feeling, sleeplessness, lightheadedness
 Increased salt intake with heavy sweating

Eating disorders
- Anorexia nervosa
 Refusal to maintain normal body weight
 Do not respond to assertions of actual appearance
 Absence of three consecutive menstrual cycles
 Strict exercise, possible menstruation
- Bulimia nervosa/binge eating disorder
 Recurrent episode of binge eating
 No control over-eating
 Compensatory mechanisms to avoid losing weight such as purging, laxatives,
and enemas
 Occurs at least twice weekly for a month
 Some patients never purge
- Treatments
 Monitor fluid and electrolyte status and daily caloric intake
 Identify non weight related interests
 Determine ability to know current weight
 Use weight related rewards
 Therapeutic modalities
 Can have coexisting issues such as abuse or addiction

Traumatic brain injury

- Emotional behavioral disturbances, labile, acting out to defend against things they
can’t remember

PTSD
- Reexperiencing of trauma
 Recurrence
 Thought intrusion
 Repetitive dreams
 Flashbacks
- Hyperarousal, always ready to fight against potential threats
- Goals to reduce symptoms and improve functioning
Cognitive disorders
- Delirium (out of one’s furrow)
 Acute onset, reversible if root cause is treated (e.g. UTI)
 Visual or tactile hallucinations
 Anxious, confused, “something doesn’t feel right”
 Dramatic change in behavior, distractibility, sleep disturbances
 ICU induced psychosis
- Dementia
 Progressive, insidious
 Long-term memory failing, no changes to LOC initially
 Loses ability to think abstractly
 Can be reversible or irreversible
 Wernicke-Korsakoff—alcohol related dementia, irreversible
- Frontotemporal lobe disease
 Dramatic change in personality
- Lewy bodies
 Intracellular bodies in neurons of the brain
 Hallucination, delusions, depression
- Vascular dementia
 Second most common dementia
 Vascular spaces diminished, causes may be stroke, diabetes, CAD
- HIV related dementia
 Active AIDs
 Classic features of dementia
- Prion disease
 Mad cow
 Seizures, personality changes, strict aseptic precautions for brain and spinal
fluid
 Highly contagious
- Huntington’s
 Autosomal, dominant
 Personality changes, limb movements
- Alzheimer’s
 See Gero notes
 P. 337
 Toilet every two hours
 Assess nutritional status
 Assess for elopement and safety
Personality disorders
- May say “it’s just the way I am”
- Difficult to treat
- Cluster A:
 Paranoid personality disorder
 Mistrustful, cold
 Schizoid personality disorder
 No interpersonal relationships
 Build trust and integrate into groups
 Schizotypal personality
 Similar to schizophrenia, but doesn’t meet all criteria
- Cluster B:
 Antisocial Personality Disorder
 Complete disregard for the rights of others
 Conduct disorder in adolescence
 Don’t acknowledge fault
 Charismatic, eloquent
 Borderline Personality Disorder
 Angry and impulsive
 Unstable relationships
 High risk for suicide, self-mutilate
 Fall in and out of love (perceives object of affection as perfect, leaves when
negative qualities appear)
 Jeffrey Dahmer
 Narcissistic Personality Disorder
 Ted Bundy and Charles Manson
 Achievement driven
 Set limits, highly manipulative
 Histrionic Personality Disorder
- Cluster C:
 Dependent
 Defensive, clingy, doesn’t like to make decisions for self
 Avoidant Personality Disorder
 Highly sensitive to criticism
 Help with interactions
 Encourage to speak up
 Obsessive Compulsive Personality Disorder
 Control freak, inflexible
 Explore interests, discuss feelings
Substance related disorders
- Addiction versus connection
- Express genuine concern, be nonjudgmental and nonthreatening
- Most common coping mechanism is denial
- Ask about legal substances first
- Affects every area of addict’s life
- Drugs
 Disulfiram: makes drinking painful
 Naltrexone: decreases pleasure of drinking
 Acamprosate: rebalances brain chemistry
 Topiramate: reduces cravings
 Ondansetron: reduces chemical reward
- Family roles in alcoholic families
 Caretaker, hero, scapegoat, mascot, lost child, rescuer