Therapeutic communication

The ability to form patient-centered relationships is fundamental and essential to effective nursing care
-Crucial to the formation of patient-centered therapeutic relationships

Factors affecting communication

Personal factors:
Psychiatric disorders- depression can slow the thinking which slows communication
-anxiety can cause a lack of concentration
-Mania causes in ability to focus for any length of time
Language barriers
Cultural differences
Cognitive factor

Types of communication

Verbal- the spoken word
Nonverbal- Tone of voice
-emphasis on certain words
-pace of speech
-body posture
-eye contact
-hand gestures
-fidgeting

How long does an order for seclusion last

Orders are good for 24 hours
under 18 2 hours at a time
over 18 4 hours at a time
Nurse can isolate pt if they are feeling threatened

When is a nurse able to decline floating to an inpatient psych unit?

If they feel uncomfortable, threatened, or like they are in harms way.

Resilience compared to recovery

recovery is the act or process of regaining or repossession of something lost
resilience is the mental ability to recover quickly from depression, illness, or misfortune

What is false imprisonment?

When a person is confined in a limited area or within an institution.
Medications that result in chemical restraint may also fit in this category of tort.
A charge may be made after a person is placed in restraints or seclusion.

What are intentional torts?

1. Assault
2. Battery
3. False Imprisonment
4. Invasion of Privacy

What are unintentional torts?

MUST HAVE
1. Duty
2. Breach of duty
3. Cause in the face and proximate cause
4. Damages
unintended acts against another person that produce injury or harm.

At what age is autism usually diagnosed?

First 3 years of life
Usually appears in early childhood

Autism assessment

1. Assess for developmental delays, uneven development, or loss of acquired abilities.
2. Assess the child's communication skills (verbal and nonverbal), sensory, social, and behavior skills
3. Assess the parent-child relationship for evidence of bonding,

What are some examples of therapeutic communication techniques?

Silence
Accepting
Giving recognition
Offering self
Giving broad openings
Placing the events in time or sequence making observations
Encouraging description of perception
Encouraging comparison
Restating

Nontherapeutic Communication Techniques

Giving premature advice
Minimizing feelings
Falsely reassuring
Making value judgments
Asking "why" questions
Asking excessive questions
Giving approval, agreeing
Disapproving, disagreeing
Changing the subject

What is milieu therapy?

refers to the overall environment (people, setting, structure, and the emotional climate)

What are the three types of prevention

primary, secondary, tertiary
are aimed at reducing the effects of mental illness by preventing its occurrence, preventing it's progression, or restoring functional ability.

Primary prevention

prevent or delay disease/illness
Ex. teaching coping skills and effective communication to prevent a mood disorder

Secondary prevention

early identification, prompt effective treatment, delay progression of disease/illness

Tertiary prevention

Treatment, Prevent disease from progressing to disability or death

What is Adderall (mixed amphetamine salts), Vyvanse (lisdexamfetamine dimesylate), and Ritalin (methylphenidate) used for?

Response: Increase attention and task-directed behavior
Reduce Impulsivity, restlessness, and distractibility
When prescribed... takes 2-4 weeks to get a good baseline, get a good assessment, look for side effects

Adderall, Vyvanse and Ritalin side effects/adverse effects

S/E
Insomnia (assess sleep)
Appetite suppression (assess weight, give with food or after meals)
Headache
Abdominal Pain (give meds with bf or lunch)
Lethargy
A/E
Agitation
Exacerbation of psychotic thought process
Growth suppression (assess weight, appeti

Maslow's Hierarchy of Needs

Provides a framework to prioritize nursing diagnosis
Needs below must be met before you can move up to the next stage

What is the criteria for involuntary admission?

Most patients are admitted to I/P care involuntarily and are placed in locked units.
Locked units provide privacy and reduce the risk of elopement

Beneficence

To do good

Nonmalfeficence

To do no harm

Autonomy

respecting the rights of others to make their own decisions

Justice

To be fair/equal

Fidelity

To be loyal/faithful

Veracity

To tell the truth, honesty

Standard of care

the degree of care that a reasonably prudent person should exercise under the same or similar circumstances

Negligence

failure to use reasonable care, resulting in damage or injury to another.

Malpractice

improper, illegal, or negligent professional activity or treatment, especially by a medical practitioner, lawyer, or public official.

Battery

intentional act of causing physical harm to someone

Freud's Psychoanalytic Theory

personality is shaped by childhood experiences and unconscious thoughts/desires

Freuds Psychoanalytical Theory stages

ID- source of all drives instincts, reflexes, and needs; can not tolerate frustration, unable to problem solve, is illogical, wants instant gratification; a screaming toddler (ID= kid, babies)
Ego- problem solver and reality tester, ego attempts to naviga

Sullivan's Interpersonal Theory

The purpose of all behavior is to get needs met through interpersonal interactions and to decrease or avoid anxiety.
Theory that dysfunctional human interaction leads to mental illness

Interpersonal therapy

treatment based on interpersonal theory that works to reduce or eliminate psychiatric symptoms, strengthen social skills and targets interpersonal problems, conflicts, and life transitions

Transference

unconscious feelings of the patient towards the nurse based on feelings towards another person
Ex. you remind me of my sister

Countertransference

Circumstances in which a nurse develops personal feelings about a client because of perceived similarity of the client to significant people in the nurse's life.

What is DSM-5?

Diagnostic and Statistical Manual of Mental Disorders
Identifies 157 disorders based on specific criteria
The disorders are broken down into 20 subcategories
Published by: American Psychiatric Association
Medical Diagnosis related

What is the NANDA-I?

North American Nursing Diagnosis Association International
Nursing Diagnosis
Is based on problems
Care determined

Paplau's Interpersonal Theory

Therapeutic relationship between nurse and client in 4 phases
1. orientation
2. identification
3. exploitation
4. resolution

What are the patients rights?

Right to treatment
-Right to be free from excessive or unnecessary meds
-Right to privacy & dignity
-Right to least restrictive environment
-Right to an attorney, clergy, or private care provider
Right to refuse treatment
-Except if the patient has a seri

What should you try for a first attempt before using restraints or seclusion?

verbal intervention (ask for cooperation)
de-escalation
reduce stimulation
active listening
provide diversion
offer PRN meds

What are the NPSG for behavioral health care?

-Identify individuals served correctly (use 2 patient identifiers)
-use medicines safely
-prevent infection
-Identify individual served safety risks (who is most likely to commmit suicide)

Patient's right to privacy

The justifiable expectation on the part of a patient that the information in his or her health record will be used only in the context of providing healthcare services
-They have the right to refuse tx, medications
-They have the right to confidentiality

Mandatory reporting

Nurses are mandated to report any suspicion of abuse (child or elder abuse, domestic violence) following facility policy.
Warn 3rd parties if they are at risk

informed consent

Patient gives consent for a procedure to be performed in full knowledge of the procedure and the risk it entails
-Make sure provider has educated patient
-Witness signature of document
-Make sure pt is competent
-Make sure pt has no questions, if they do

Entry to Acute Inpatient Care

-Direct admission on referral
-Emergency department or crisis service
-can be voluntary or involuntary

Voluntary admission

admission to a facility sought by patient or guardian

What is informal admission?

One type of voluntary admission that is similar to any general hospital admission in which there is no formal or written application; the patient is free to stay or leave, even against medical advice.

involuntary commitment

-A court-ordered admission to a facility without the patient's consent
-Pink slip
-The patient must be mentally ill
-The patient must pose a danger to self or others
-They must be unable to provide for their basic needs
-Their mental illness prevents help

Emergency commitment

when an acutely disturbed individual is temporarily confined, typically for no more than a few days.

Types of discharge

Conditional- usually requires O/P tx for a specified time frame
Unconditional- basic hospital release
AMA

When can a 72 hour hold be extended beyond 72 hours?

The doctor can extend the order if they feel they are still a risk of harming themselves or others.

When is the nurse/HCP required to share information with authorities/parents?

When the patient is expressing threatening behavior it is your duty to report and warn anyone that could be harmed.

Seclusion

-In an emergency a nurse may seclude patient but must obtain an order IMMEDIATELY
-Need a new order every 24 hours
-Never a standing order
-Adults 18 and up limited to 4 hours
-9-17 are limited to 2 hours
-9 and under are limited to 1 hour
-After 24 hours

attention deficit hyperactivity disorder

-ADHD
-show an inappropriate degree of inattention, impulsiveness, and hyperactivity.
-Occurs in early childhood before age 12
-Higher in boys than girls
-Often have comorbid disorders (oppositional defiant disorder, conduct disorder, disruptive mood diso

behaviors and symptoms of ADHD

hyperactivity
impulsivity
poor peer relationships
poor social boundaries
intrusive behaviors
interrupts others
may be distracted easily
disorganized
become easily bored
lose things frequently
may be unable to complete challenging tasks

Attention deficit disorder

ADD
A child that is inattentive but not hyperactive

Assessment ADHD

1. Gather data from parents and caregivers/adults that are around the child
2. Assess social skills, friendship history, problem-solving skills, and school performance.
3. Assess for comorbidities such as anxiety or depression
4. Assess for any indicators

ADHD treatment/implementation

individual, group, and family therapy
intensive outpatient programs
specialized charter schools
hospitalization
CBT
Stimulant drugs good for attention Ritalin (methylphenidate) and Adderall (mixed amphetamine salts)
meds for aggressive behaviors: Abilify,

What activities would be appropriate for a child with ADHD

music
storytelling
biking
individual sports (tennis, swimming, martial arts)
board games

ADHD evaluation

-response to pharmacotherapy (are they effective)
-Symptom improvement?
-Are the expectations in place realistic?
-What types of services do they need to support their attempts in implementing effective behavioral plans?
-Safety

General interventions for children and adolescents

-Behavioral interventions-reward desired behavior
-Play therapy
-Bibliotherapy- listening to or reading stories
-Expressive arts therapy- drawing, painting, sculpting
-Journaling
-Music therapy
-Family interventions- family counseling
-Psychopharmacology

What is the leading cause of disability in the US?

neuropsychiatric disorders- including mixed anxiety-depressive disorder

79% of abuse is what?

Neglect

Dopamine association with mental health?

Decrease:
Parkinsons
Depression
Increase:
Schizophrenia
Mania

Norepinephrines association with mental health

Decrease:
Depression
Increase:
Mania
Anxiety states
Schizophrenia

Serotonins association with mental health

Decrease:
Depression

Histamines association with mental health

Decrease:
Sedation
Weight Gain

intrapersonal communication

self-talk

interpersonal communication

direct, face-to-face communication between two or more people

Restating

uses the client's exact words

Paraphrasing

Putting into words the ideas or feelings you have perceived from the message
"What I think you said is...

bad communication techniques

-NEVER ASK WHY
-Offering opinion
-Giving false assurance
-Giving advice
-Changing the subject

good communication techniques

-Asking open ended questions
-Maintain eye contact/get on their level
-Use therapeutic touch (when appropriate)

Silence

gives the person time to collect thoughts or think through a point
ex. encouraging a person to talk by waiting for the answers

Accepting

Indicates that the person has been understood. An accepting statement does not necessarily indicate agreement but is nonjudgmental.
ex. Yes, I follow what you say

Giving recognition

Indicates awareness of change and personal effort. Does not imply good, bad, right, wrong.
Ex: "Good morning, Mr. James, You've combed your hair today, I see you've eaten your whole lunch

Offering self

Offers presence, interest, and a desire to understand. Is not offered to get the person to talk or behave in a specific way.
ex. "I would like to spend time with you

Offering general leads

Allows the other person to take direction in the discussion. Indicates that the nurse is interested in what comes next.
ex. "Go on" "Tell me about it

Giving broad openings

Clarifies that the lead is to be taken by the patient. However, the nurse discourages pleasantries and small talk.
ex. "Where would you like to begin", "What are you thinking about

Placing the events in time or sequence

Puts events and actions in better perspective. Notes cause-and-effect relationships and identifies patterns of interpersonal difficulties.
ex. "What happened before

Making observations

Calls attention to the PT's BEHAVIOR (e.g. nail biting).
Encourages the PT to notice the behavior to describe thoughts & feelings for mutual understanding.
*
NOTE: helpful w/ MUTE & WITHDRAWN people
*
EXAMPLE
"You appear tense."
"I notice you're biting yo

Encouraging description of perception

Increases the nurse's understanding of the patient's perceptions. Talking about feelings and difficulties can lessen the need to act them out inappropriately.
ex. "What do these voices seem to be saying", "Tell me when you feel anxious

Encouraging comparison

Brings out recurring themes in experiences or interpersonal relationships. Helps the person clarify similarities and differences.
ex. "Has this ever happened before", "Was it something like...

Reflecting

Directs questions, feelings, and ideas back to the patient. Encourages the patient to accept his or her own ideas and feelings. Acknowledges the patient's right to have opinions and make decisions and encourages the patient to think of self as a capable p

Focusing

Concentrates attention on a single point. It is especially useful when the patient jumps from topic to topic. If a person is experiencing a severe or panic level of anxiety, the nurse should not persist until the anxiety lessens.
ex. "This point you are m

Exploring

Examines certain ideas, experiences, or relationships more fully. If the patient chooses not to elaborate by answering no, the nurse does not probe or pry. In such a case, the nurse respects the patient's wishes.
ex. "Would you describe it more fully

Giving information

Makes facts that client needs available.
Ex: "My purpose for being here is..., this medication is for..., this test will determine...

Seeking clarification

Helps patients clarify their own thoughts and maximize mutual understanding between nurse and patient.
ex. "I am not sure I follow you

Presenting reality

Indicates what is real. The nurse does not argue or try to convince the patient, just describes personal perceptions or facts in the situation.
ex. "Your mother is not here, I am a nurse

Voicing doubt

expressing uncertainty as to the reality of client's perception
ex. "That's hard to believe

Seeking consensual validation

Clarifies that both the nurse and patient share mutual understanding of communications. Helps the patient become clearer about what he or she is thinking.
ex. "Tell me whether my understanding agrees with yours

Verbalizing the implied

Puts into concrete terms what the patient implies, making the patient's communication more explicit.

Encouraging evaluation

Aids the patient in considering people and events from the perspective of the patient's own set of values.

Attempting to translate into feelings

Responds to the feelings expressed, not just the content. Often termed decoding.

Suggesting collaboration

Emphasizes working with the patient, not doing things for the patient. Encourages the view that change is possible through collaboration.

Summarizing

Brings together important points of discussion to enhance understanding. Also allows the opportunity to clarify communications so that both nurse and patient leave the interview with the same ideas in mind.

Encouraging formulation of a plan of action

Allows the patient to identify alternative actions for interpersonal situations the patient finds disturbing
ex. when anger or anxiety is provoked

operant conditioning

the learning of voluntary behavior through the effects of pleasant and unpleasant consequences to responses

Restraints

-Needs physicians order within 1 hour of application
-No PRN orders
-Chart q15 mins
-Two fingers between pt and restraint
-Use quick release knot
-Place on a non movable part of bed frame (no side rail)
-Put belt restraints over gown or clothing
-Frequent

interpersonal therapy

treatment that strengthens social skills and targets interpersonal problems, conflicts, and life transitions

What interview technique would you use for a mental health assessment on an adolescent?

HEADSSS
H-Home environment
E- Education and Employment
A- Activities
D- Drug, Alcohol, or tobacco use
S- Sexuality
S-Suicide
S- Safety

What are techniques for managing disruptive behaviors?

-Behavioral contract
-Collaborative and proactive solutions
-Counseling
-Modeling
-Role playing
-Planned ignoring
-Use of signals or gestures
-Physical distance and touch control
-Redirection
-Additional affection

Psychobiology and psychopharmacology

-Brain function and activity
-Maintain homeostasis
-Regulation of ANS and hormones
-Control of biological drives and behavior
-Cycle of sleep and wakefulness
-Circadian rhythm
-Conscious mental activity
-Memory
-Social skills