Psychiatric Nursing Assessment and Interventions, Exams of Nursing

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Addressing Higher-Level Needs

and Treatment Choices in

Psychiatric Care

Essentials of Psychiatric Mental Health

Nursing: Concepts of Care in Evidence-Based

Practice

Understanding Mental Illness

Assessing Mental Illness : The nurse should assess that the client's daily functioning is not impaired. The client who experiences feelings of sadness after the loss of a pet is responding within normal expectations. Without significant impairment, the client's distress does not indicate a mental illness.

Determining Risk for Mental Illness : The nurse should determine that the client is at risk for mental illness when responses to stress are maladaptive and interfere with daily functioning. The DSM-5 indicates that in order to be diagnosed with a mental illness, daily functioning must be significantly impaired.

Stress Responses in Identical Twins : The nurse should explain to the parents that, although the twins have identical DNA, there are several other factors that affect reactions to stress. Mental health is a state of being that is relative to the individual client. Environmental influences and temperament can affect stress reactions.

Receptiveness to Psychiatric Treatment : The nurse should anticipate that the client of Jewish culture would place a high importance on preventative health care and would consider mental health as equally important as physical health. Women are also more likely to seek treatment for mental health problems than men.

Defense Mechanisms : The nurse should determine that defense mechanisms can be appropriate during times of stress. The client with no defense mechanisms may have a lower tolerance for stress, thus leading to anxiety disorders. Defense mechanisms should be confronted when they impede the client from developing healthy coping skills.

Addressing Psychosocial Factors : The nurse should attempt to educate the client on the negative effects of excessive stress on medical conditions. It is not appropriate to skip physiological and psychosocial questions, as this would lead to an inaccurate assessment.

Displacement as a Defense Mechanism : The nurse should expect that the client using the defense mechanism displacement would criticize a coworker after being confronted by the boss. Displacement refers to transferring feelings from one target to a neutral or less- threatening target.

Reaction Formation as a Defense Mechanism : The nurse should identify that the boy is using reaction formation as a defense mechanism. Reaction formation is the attempt to prevent undesirable thoughts from being expressed by expressing opposite thoughts or behaviors.

Concepts of Mental Health and Illness

Neurosis : The nurse should define the concept of neurosis with the following characteristics: the client feels helpless to change his or her situation, the client is aware that he or she is experiencing distress, the client is aware the behaviors are maladaptive, the client is unaware of the psychological causes of the distress, and the client experiences no loss of contact with reality.

Psychosis : The nurse should understand that the client with psychosis experiences little distress owing to his or her lack of awareness of reality. The client with psychosis is unaware that his or her behavior is maladaptive or that he or she has a psychological problem.

Denial as a Defense Mechanism : The clients statement "I don't drink too much!" alerts the nurse to the use of the defense mechanism of denial. The client is refusing to acknowledge the existence of a real situation and the feelings associated with it.

Acceptance Stage of Grief : The nurse should evaluate that the client is in the acceptance stage of grief because during this stage of the grief process, the client would be able to focus on the reality of the loss and its meaning in relation to life.

Maslow's Hierarchy of Needs

Self-Actualization : The nurse should identify that the client who possesses a feeling of self-fulfillment and realizes his or her full potential has achieved self-actualization, the highest level on Maslow's hierarchy of needs.

Priority Intervention : The nurse should immediately intervene when a client exhibits aggressive behavior toward another client. Safety and security are considered lower-level needs according to Maslow's hierarchy of needs and must be fulfilled before other higher-level needs can be met.

DSM-5 Definition of Mental Disorder : A health condition characterized by significant dysfunction in an individual's cognitions, or behaviors that reflects a disturbance in the psychological, biological, or

developmental process underlying mental functioning, is the new DSM-5 definition of a mental disorder.

Symptoms of Anxiety

Symptoms of Anxiety : The nurse should assess that fidgeting, laughing inappropriately, and nail biting are indicative of heightened stress levels. The client would not be diagnosed with mental illness unless there is significant impairment in other areas of daily functioning.

Definition of Anxiety : Anxiety is a diffuse apprehension that is vague in nature and is associated with feelings of uncertainty and helplessness.

Definition of Grief : Grief is a subjective state of emotional, physical, and social responses to the loss of a valued entity.

Grief

Grief is a subjective state of emotional, physical, and social responses to the loss of a valued entity. Townsend considers this a core concept.

Biological Implications

Medications and Depression : The nurse should advise the client that medications address biological factors, but there are other factors that affect mood. The nurse should educate the client on environmental and interpersonal factors that can lead to depression.

Limbic System and Emotions : The nurse should explain to the client that the limbic system is largely responsible for one's emotional state. This system is often called the "emotional brain" and is associated with feelings, sexuality, and social behavior.

Sympathetic Nervous System and Stress : The nurse should identify that the sympathetic nervous system plays a major role during stressful situations. The sympathetic nervous system prepares the body for the fight-or-flight response.

Circadian Rhythms and Psychopathology : The client's statement, "I'm a morning person. I get my best work done before noon," demonstrates an understanding that circadian rhythms may influence a variety of regulatory functions, including the sleep-wake cycle, regulation of body temperature, and patterns of activity.

Adoption Studies and Psychiatric Research : The nurse should determine that all the studies mentioned (studies involving children with mentally ill biological parents raised by adoptive parents who were mentally healthy, studies involving children with mentally healthy biological parents raised by adoptive parents who were mentally ill,

studies involving monozygotic twins from mentally ill parents raised separately by different adoptive parents, and studies involving monozygotic twins raised together by mentally ill biological parents) could possibly benefit the psychiatric community. These studies may reveal research findings relating genetic links to mental illness.

Psychoimmunology and Stress : The nurse should recognize that the client's diagnosis of ulcerative colitis six months after the death of her husband and children validates the study perspective of psychoimmunology, which studies the effects of social and psychological factors on the functioning of the immune system.

Neurotransmitters and Schizophrenia : The nurse should recognize that neurotransmitters play an essential function in the role of human emotion and behavior, and that the withdrawn behavior and lack of emotion exhibited by the client with schizophrenia may be due to an alteration in neurotransmitters.

Neurotransmitter Reuptake : The nursing instructor should explain that the process by which neurotransmitters are released into the synaptic cleft and returned to the presynaptic neuron is termed reuptake.

Norepinephrine and the Fight-or-Flight Response : The nurse should associate the neurotransmitter norepinephrine with the fight-or- flight response, as norepinephrine produces activity in the sympathetic postsynaptic nerve terminal and is associated with the regulation of mood, cognition, perception, locomotion, and sleep and arousal.

Dopamine and Catatonic Schizophrenia : The nurse should expect that elevated dopamine levels might be an attributing factor to the client's current level of functioning in catatonic schizophrenia. Dopamine functions include regulation of movements and coordination, emotions, and voluntary decision-making ability.

Psychoimmunology and Grief : The therapist's recommendations of encouraging open discussion of feelings, proper nutrition, and exercise should be based on the knowledge that the client has been exposed to stressful stimuli and is at an increased risk to develop illness because of the effects of stress on the immune system.

Prolactin and Schizophrenia : Although the exact mechanism is unknown, there may be some correlation between decreased levels of the hormone prolactin and schizophrenia.

Limbic System and the "Emotional Brain" : The limbic system is often referred to as the "emotional brain" and is largely responsible for one's emotional state, as well as being associated with feelings, sexuality, and social behavior.

Growth Hormone and Anorexia Nervosa : Research has found a correlation between abnormal levels of growth hormone and anorexia nervosa.

Acetylcholine and Memory/Motor Function : The nurse should correlate memory deficits and decreased motor function with decreased levels of acetylcholine, as acetylcholine is a major effector chemical of the autonomic nervous system and is involved in functions such as sleep regulation, pain perception, the modulation and coordination of movement, and memory.

Norepinephrine and Major Depressive Episode : The nurse should recognize that a decrease in norepinephrine level would play a significant role in the development of major depressive disorder, as norepinephrine regulates mood, cognition, perception, locomotion, cardiovascular functioning, and sleep and arousal.

Dopamine and Schizophrenia Spectrum Disorder : The nurse should expect that an increase in dopamine activity might play a significant role in the development of schizophrenia spectrum disorder, as dopamine functions include the regulation of emotions, coordination, and voluntary decision-making ability.

Causes of Anorexia Nervosa : The nurse should explain to the client that there is a possible correlation between anorexia nervosa and decreased levels of growth hormones and gonadotropin.

Increased TSH and Symptoms : The nurse should associate depression and fatigue with increased levels of thyroid-stimulating hormone (TSH), as TSH is only increased when thyroid levels are low, as in the diagnosis of hypothyroidism.

Psychobiology : Psychobiology is the study of the biological foundations of cognitive, emotional, and behavioral processes.

Ethical and Legal Issues in Psychiatric

Nursing

Ethical Frameworks

Christian Ethics : The charge nurse in the given scenario is operating from a Christian ethics framework. This framework emphasizes that decisions about right and wrong should be centered in love for God and in treating others with the same respect and dignity with which we would expect to be treated.

Ethical Egoism : The nursing applicant who states that the job will pay the bills and the workload is light enough for them is operating from an ethical egoism framework. This framework promotes the idea that decisions are made based on what is good for the individual and may not take the needs of others into account.

Ethical Principles

Responsibility : The coworker's lack of involvement in the unethical action of the nurse administering an extra dose of narcotic tranquilizer to an agitated client can be interpreted as an unethical action. The coworker has a responsibility to report any observed unethical actions.

Autonomy : The unit manager's policy regarding voluntary client participation in group therapy preserves the ethical principle of autonomy. The principle of autonomy presumes that individuals are capable of making independent decisions for themselves and that healthcare workers must respect these decisions.

Intentional Tort : A nurse who intentionally physically places an irritating client in restraints has committed an intentional tort, which is a violation of civil law in which an individual has been wronged.

Respect : The most appropriate nursing action in the case of an involuntarily committed client who is verbally abusive and threatens to sue is to continue professional attempts to establish a positive working relationship with the client. The client should be respected and has the right to assert grievances if rights are infringed.

Overriding Refusal : Health-care professionals can override treatment refusal by an actively suicidal or homicidal client, as this situation should be treated as an emergency, and treatment may be performed without informed consent.

Involuntary Commitment : The nurse should identify the client threatening to commit suicide as eligible for involuntary commitment, as the suicidal client who refuses treatment is in danger and needs emergency treatment.

Endangering Safety : The nurse would have the right to medicate a client against their wishes if the client physically attacks another client, as this client poses a significant risk to safety and is incapable of making informed choices.

Confidentiality : The most appropriate action by the nurse is to refuse to give any information to the caller about whether an individual has been a client in the facility, as this would be considered protected health information (PHI) and should not be disclosed without prior client consent.

Autonomy : The nurse should provide the client with information on several medications to facilitate the client's autonomy and support their ability to make independent choices about the management of their depression.

Justice : The nurse should determine that the ethical principle of justice has been violated by the physician's actions of refusing to treat clients without insurance and prematurely discharging those whose insurance

benefits have expired, as the principle of justice requires that individuals should be treated equally.

Veracity : The nurse who tricks a client into seclusion has violated the ethical principle of veracity, which refers to one's duty to always be truthful and not intentionally deceive or mislead clients.

Competence : The nurse should question the validity of informed consent when the client incorrectly reports their spouse's name, date, and time of day, as this indicates that the client may not be competent to make informed choices.

Respect for Autonomy : It is ethically appropriate for the nurse to allow the client diagnosed with schizophrenia to decline the medication and provide accurate documentation, as the client's right to refuse treatment should be upheld, unless the refusal puts the client or others in harm's way.

Assault and Battery : The nurse who threatens to tie down the client and then does so, against the client's wishes, has committed both the acts of assault and battery, as assault refers to an action that results in fear and apprehension that the person will be touched without consent, and battery is the touching of another person without consent.

Least Restrictive Alternative : The least-restrictive alternative for the confused and wandering geriatric client would be monitoring by an ankle bracelet, as the client does not pose a direct dangerous threat to self or others, and neither physical restraints nor seclusion would be justified.

HIPAA Violation : The nurse has violated the Health Insurance Portability and Accountability Act (HIPAA) by revealing that the client had been admitted to the psychiatric unit to the brother, who was not on the client's approved call list.

Involuntary Commitment Criteria

Criteria for Involuntary Commitment

According to the information provided, a physician can consider involuntary commitment of a client in the following situations:

The client is dangerous to others. The client is gravely disabled and unable to meet basic needs. The client is suicidal.

The physician can consider involuntary commitment when the client meets one or more of these criteria. If the physician determines that the client is mentally incompetent, consent should be obtained from the legal guardian or court-approved guardian or conservator. In situations where time does not permit court intervention, a hospital administrator may give permission for involuntary commitment.

Rights and Ethics

Definition of a Right

A right is a valid, legally recognized claim or entitlement, encompassing both freedom from government interference or discriminatory treatment and an entitlement to a benefit or a service. A right is absolute when there is no restriction whatsoever on the individual's entitlement.

Definition of Ethics

Ethics is a branch of philosophy that deals with systematic approaches to distinguishing right from wrong behavior. Bioethics is the term applied to these principles when they refer to concepts within the scope of medicine, nursing, and allied health.

Psychopharmacology

Typical vs. Atypical Antipsychotics

The key differences between typical and atypical antipsychotics are:

Atypical antipsychotics produce fewer extrapyramidal effects compared to typical antipsychotics. There is no evidence that atypical antipsychotics remain in the system longer or act more quickly to reduce delusions. Atypical antipsychotics are not risk-free for neuroleptic malignant syndrome (NMS).

Neuroleptic Malignant Syndrome (NMS)

The cardinal sign of NMS is an increased temperature. Other signs and symptoms include muscle rigidity, altered mental status, and autonomic instability.

Anticholinergic Effects of Antipsychotics

Fluphenazine (Prolixin) administration can produce anticholinergic effects, such as dry mouth, blurred vision, and constipation, due to cholinergic receptor blockade.

Tardive Dyskinesia (TD)

Behaviors characteristic of TD include grimacing, lip smacking, and other abnormal movements of voluntary muscle groups, particularly the face, mouth, tongue, and digits.

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Improving Medication Compliance

For a patient diagnosed with schizophrenia who is not taking the prescribed oral haloperidol (Haldol), the nurse can promote medication compliance by administering haloperidol decanoate, a depot medication given intramuscularly every 2 to 4 weeks.

Tricyclic Antidepressants

Tricyclic antidepressants increase the availability of norepinephrine and serotonin by blocking their reuptake.

Monoamine Oxidase Inhibitors (MAOIs)

Patients taking MAOIs must observe a tyramine-free diet to prevent hypertensive crisis. Liver is a food that contains large amounts of tyramine and should be avoided.

Selective Serotonin Reuptake Inhibitors (SSRIs)

Compared to other antidepressant medication groups, SSRIs have the best side-effect profile, which was likely an important factor in the physician's decision to prescribe sertraline (Zoloft) for a patient with symptoms of major depression.

Lithium Therapy

Patients on lithium therapy must be educated about the importance of maintaining a consistent dietary salt intake, as changes in salt intake can affect lithium levels.

Benzodiazepines

Benzodiazepines have a rapid onset of peak action, and shorter-acting benzodiazepines are more difficult to taper and potentially cause more problems with withdrawal.

Combining a benzodiazepine with alcohol or other central nervous system (CNS) depressants is potentially fatal.

Poststroke Depression

For a patient with poststroke depression receiving an SSRI, the rationale for giving the medication at breakfast and again at midday is to prevent insomnia, as CNS stimulants may cause insomnia if given late in the day.

Lithium Toxicity

The priority nursing action for a patient experiencing symptoms of moderate lithium toxicity (coarse hand tremor, diarrhea, vomiting, lethargy, and mild

confusion) is to hold the lithium, obtain a stat lithium level, and notify the physician.

Rapid Cycling Bipolar Disorder

For a patient with rapid cycling bipolar disorder not responding well to lithium, the nurse should inform the patient that valproic acid is a first-line agent that is proving effective for the treatment of rapid cycling bipolar disorder.

Therapeutic Effects of Medication and

Appropriate Use

Therapeutic Effects of Medication

The patient recognizes the therapeutic effects of the medication in assisting her to work effectively with the therapist.

Inappropriate Use of Medication

The patient has questions about having to take the medication for the rest of her life, which shows uncertainty about the long-term use of the medication. The patient is embarrassed and does not want anyone to know she is on this kind of medication, indicating a stigma associated with the treatment. The patient wants to ask for a PRN (as needed) dose to help her sleep instead of worrying about her kids, which suggests inappropriate use of the medication for purposes other than the intended therapeutic effect.

Medication Side Effects

Pseudoparkinsonism

A patient taking chlorpromazine (Thorazine) for 2 weeks experiences drooling, hand tremors, and a shuffling gait, which are symptoms of pseudoparkinsonism associated with dopamine blockade. Pseudoparkinsonism is a common side effect of typical antipsychotic medications like chlorpromazine.

Gastrointestinal Side Effects of Valproate

Patients taking valproate may experience gastrointestinal side effects such as indigestion, heartburn, and nausea. The nurse should recommend the administration of a histamine- antagonist, such as famotidine (Pepcid), to help alleviate these side effects.

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Lithium Toxicity

A patient's serum lithium level is reported as 1.9 mEq/L, which is high and suggests the patient may be experiencing symptoms of lithium toxicity. The nurse should immediately assess the patient for signs and symptoms of lithium toxicity, as this is the priority action.

Antipsychotic Medication Effects

Typical antipsychotic medications produce improvement in the positive symptoms of schizophrenia, such as hallucinations and delusions. Negative symptoms and cognitive functioning tend to show less improvement with typical antipsychotic therapy.

Orthostatic Hypotension with Ziprasidone

When IM ziprasidone (Geodon) is administered to an assaultive patient during a psychiatric emergency, the nurse should primarily assess for orthostatic hypotension, which is the most likely side effect to appear due to alpha1 receptor blockade.

Akathisia with Haloperidol

A patient who began haloperidol (Haldol) therapy 24 hours ago reports feeling jittery and unable to sit or stand still, which is indicative of akathisia, an extrapyramidal side effect that usually occurs early in the course of treatment with a typical antipsychotic drug.

Relationship Development and Therapeutic

Communication

Pre-Interaction Phase

The most essential task for a nurse to accomplish prior to forming a therapeutic relationship with a client is to clarify personal attitudes, values, and beliefs, which is called self-awareness.

Orientation Phase

The priority nursing action during the orientation phase of the nurse- client relationship should be to establish rapport and develop treatment goals.

Working Phase

During the working phase, the nurse should expect the client to gain insight and incorporate alternative behaviors.

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The client may overcome resistance, problem-solve, and continually evaluate progress toward goals. The client may express resistance by stating, "I really don't want to talk any more about my childhood abuse," which reflects the client's anxiety as painful issues are discussed.

Therapeutic Communication Techniques

Restatement involves repeating the main idea of what the client has said, allowing the client to know whether the statement has been understood and providing an opportunity to continue. Formulating a plan of action helps the client explore alternatives, such as when the nurse asks, "Other than drinking, what alternatives have you explored to decrease anxiety?" Offering general leads, such as "Yes, I see. Go on," encourages the client to continue sharing information. Giving reassurance, such as "Things will look better tomorrow after a good night's sleep," is a nontherapeutic communication technique that devalues the client's feelings. Broad openings, such as "What would you like to talk about?", allow the client to take the initiative in introducing the topic and emphasize the importance of the client's role in the interaction.

Nonverbal Communication

Maintaining an uncrossed arm and leg posture is a nonverbal behavior that reflects the "O" (open posture) in the active-listening acronym SOLER.

The SOLER Technique and Effective Feedback

in Nursing

The SOLER Technique

The acronym SOLER includes the following elements for effective communication with clients:

S - Sitting squarely facing the client O - Observing and maintaining an open posture L - Leaning forward toward the client E - Establishing eye contact R - Relaxing

These elements help create a therapeutic environment and demonstrate the nurse's engagement and attentiveness during interactions with the client.

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Effective Feedback

Effective feedback from a nurse should have the following characteristics:

Descriptive : The feedback should describe the specific behavior or action, rather than making judgments. Specific : The feedback should be directed towards a particular behavior that the person has the capacity to modify. Imparts information : The feedback should provide the client with critical information, rather than offering advice. Avoids advice or evaluation : The feedback should not be used to give advice or evaluate the client's behaviors.

An example of effective feedback would be: "Surely you didn't do this deliberately, but you breached confidentiality by using the client's name on your worksheet."

Purposes of Providing Feedback

The primary purpose of a nurse providing appropriate feedback is to give the client critical information, not to:

Give the client good advice Advise the client on appropriate behaviors Evaluate the client's behavior

Responding to Client Behaviors

Dependent Behaviors : When a client exhibiting dependent behaviors asks, "Do you think I should move from my parents' house and get a job?", the most appropriate nursing response is to encourage the client to explore all options: "Let's discuss and explore all of your options."

Guilt Reactions : When a mother rescues two of her four children from a house fire and expresses guilt, the best nursing response is to validate the client's feelings: "You're experiencing feelings of guilt, because you weren't able to save your children."

Obsessive-Compulsive Behaviors : When a client with obsessive- compulsive disorder (OCD) exhibits continuous hand-washing that prevents unit activity attendance, the nurse should collaborate with the client to find a solution: "Let's figure out a way for you to attend unit activities and still wash your hands."

Characteristics of a Therapeutic Nurse-Client Relationship

The following characteristics should be included in a therapeutic nurse- client relationship:

Promoting client insight into problematic behavior Collaborating to set appropriate goals Meeting the physical and psychological needs of the client

Ensuring therapeutic termination

The nurse's own psychological needs should never be addressed within the nurse-client relationship.

Communication and Message Conveyance

Individuals can communicate messages through various verbal and nonverbal means, such as:

Spanking a child Isolating oneself and playing loud music Sporting a tattoo Writing "No one understands me"

It is estimated that 70-80% of communication is nonverbal.

Rapport

Rapport implies special feelings between the client and nurse, based on acceptance, warmth, friendliness, common interest, a sense of trust, and a nonjudgmental attitude. Establishing rapport may be accomplished by discussing non-health-related topics.

Countertransference

Countertransference refers to a nurse's behavioral and emotional response to a client, which may be related to unresolved feelings from the nurse's past or generated in response to the client's transference feelings.

Nursing Outcomes for Insomnia

Insomnia Related to Paranoid Thinking

A client has a nursing diagnosis of Insomnia related to paranoid thinking, as evidenced by morning napping and difficulty falling/staying asleep.

Appropriate Nursing Outcome

The client will sleep seven uninterrupted hours by day four of hospitalization.

Rationale: - Nursing outcomes should be derived from the diagnosis, measurable, and include a time estimate for attainment. - The outcome must also be realistic for the client's capabilities. - This outcome is accurately written and appropriate for a client diagnosed with insomnia.

Nursing Diagnosis: Risk for Injury

Assessment Data Leading to the Diagnosis

The client is receiving ECT and is diagnosed with Parkinsonism.

Rationale: - A client receiving ECT and diagnosed with Parkinsonism is at risk for injury. - History of suicide attempts, hopelessness, and disorganized thoughts would not lead the nurse to formulate a nursing diagnostic stem of "Risk for injury."

Developing Nursing Outcomes

Instructor's Guidance

The best response by the instructor is: Look at your client's problems and set a realistic, achievable goal. With client collaboration, outcomes should be based on client problems.

Rationale: - Client outcomes are most realistic and achievable when there is collaboration among the interdisciplinary team members, the client, and significant others.

Nursing Diagnosis: Disturbed Sensory Perception

Rationale

The nursing diagnosis "Disturbed sensory perception" accurately reflects the client's symptoms of hearing things that others do not.

Rationale: - The nursing diagnosis describes the client's condition and facilitates the prescription of interventions.

Psychiatric-Mental Health Nursing Interventions

The following nursing interventions fall within the standards of psychiatric- mental health clinical nursing practice for a nurse generalist: 1. Assist the client to perform activities of daily living. 2. Encourage the client to discuss triggers for relapse. 3. Educate the family about signs and symptoms of alcohol dependence and withdrawal.

Rationale: - These interventions are within the scope of practice for a psychiatric-mental health nurse generalist. - Consulting with other clinicians and using prescriptive authority are within the scope of practice for psychiatric-mental health advanced practice registered nurses.

Characteristics of Accurately Developed Client Outcomes

The following characteristics of accurately developed client outcomes should a nurse identify: 1. Client outcomes are specific and measurable. 2. Client outcomes are realistically based on client capability.

Rationale: - Client outcomes should be specific, measurable, and realistically based on the client's capability. - Outcomes should be derived from the diagnosis and should include a time estimate for attainment. - Outcomes are most effective when formulated cooperatively by the interdisciplinary team members, the client, and significant others.

Steps of the Nursing Process

The correct order of the nursing interventions through the steps of the nursing process is: 1. Measure a client's vital signs and review past history.

2. Recognize and document the client's problem. 3. Aim, with client collaboration, for a seven-hour night's sleep. 4. Encourage deep breathing and teach relaxation techniques. 5. Determine if an anti-anxiety medication is decreasing a client's stress.

Rationale: 1. Measuring a client's vital signs and reviewing past history is a nursing intervention that occurs in the assessment step. 2. Recognizing and documenting the client's problem occurs in the nursing diagnosis step. 3. Setting a goal with client collaboration for a seven-hour night's sleep occurs in the planning step. 4. Encouraging deep breathing and teaching relaxation techniques occur in the implementation step. 5. Determining if an anti- anxiety medication is decreasing a client's stress occurs in the evaluation step.

Nursing Diagnosis

A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Rationale: - Nursing diagnoses are clinical judgments about individual, family, or community experiences/responses to actual or potential health problems/life processes. - A nursing diagnosis provides the basis for selection of nursing interventions to achieve outcomes for which the nurse has accountability.

Milieu Therapy - Therapeutic Community

Basic Assumption of Milieu Therapy

Every interaction is an opportunity for therapeutic intervention.

Rationale: - The nurse's response should be guided by the basic assumption that every interaction is an opportunity for therapeutic intervention. - The nurse can use milieu therapy to effect behavioral change and improve psychological health and functioning.

Nursing Response to Client Conflict

The appropriate nursing response is: Let's discuss ways to approach Peter with your concerns.

Rationale: - The nurse should restate the client's feeling and develop a plan with the client to solve the problem. - According to Skinner, every interaction is an opportunity for therapeutic intervention to improve communication and relationship-development skills.

Purpose of Group Therapy

The purpose of group therapy is to learn and practice new coping skills.

Rationale: - The nurse should explain to the client that the purpose of group therapy is to learn and practice new coping skills. - The client owns their environment and can make decisions to attend group or not.

Milieu Providing Structure

The milieu, or therapeutic community, provides the client with structured programming that may be missing in the home environment.

Rationale: - The therapeutic community provides a structured schedule of activities in which interpersonal interaction and communication with others are emphasized. - Time is also devoted to personal problems and focus groups.

Promoting Self-Reliance in Medication Administration

The psychiatric nurse promoting self-reliance would encourage clients to request their medications at the appropriate times.

Rationale: - Nurses are responsible for the management of medication administration on inpatient psychiatric units, but nurses must work with clients to encourage self-reliance and responsibility, which may result in independent decision-making, leading to medication adherence.

Appropriate Education Group Topic

The nurse should identify that teaching clients about stress management is an appropriate education group topic.

Rationale: - Nurses should be able to perform the role of client teacher in the psychiatric area. - Nurses need to be able to assess a client's learning readiness. - Other topics for education groups include medical diagnoses, side effects of medications, and the importance of medication adherence.

Rationale for Including Family in Therapy

The best rationale for including the client's family in therapy within the inpatient milieu is to facilitate discharge from the hospital.

Rationale: - Family members are invited to participate in some therapy groups and to share meals with the client in the communal dining room. - Family involvement may also serve to prevent the client from becoming too dependent on the therapeutic environment.

Democratic Self-Government in the Milieu

A democratic form of self-government in the milieu contributes to client therapy by setting the expectation that all clients should be treated on an equal basis.

Rationale: - Clients participate in the decision-making and problem-solving aspects that affect the treatment setting. - The norms, rules, and behavioral limits are established by the staff and clients, and all individuals have input.

Consulting the Interdisciplinary Team Member

The nurse should consult with the clinical psychologist to obtain psychological testing for the client.

Rationale: - Clinical psychologists can administer, interpret, and evaluate psychological tests to assist in the diagnostic process.

Prioritizing the Milieu Manager's Activities

The milieu manager should prioritize searching newly admitted clients for hazardous objects.

Rationale: - Ensuring the safety of the therapeutic environment is a key responsibility of the milieu manager.

Interdisciplinary Treatment Team in

Psychiatry

Interdisciplinary Treatment Team Members

The interdisciplinary treatment team in psychiatry typically includes the following members:

Psychologist Occupational therapist Recreational therapist Art therapist Mental health technician Chaplain

Additionally, the following professionals may also participate in the interdisciplinary treatment team:

Psychiatrist Psychiatric nurse Psychiatric social worker Music therapist Psychodramatist Dietitian

The interdisciplinary treatment team works collaboratively to address the diverse needs of the psychiatric client, ensuring that the client's safety and physiological needs are met.

Therapeutic Community

Conditions that Promote a Therapeutic Community

The following conditions promote a therapeutic community:

Unit responsibilities are assigned according to client capabilities. A democratic form of government exists.

Therapeutic communities are structured and provide therapeutic interventions that focus on communication and relationship-development skills.

Milieu Therapy

Milieu therapy is defined as a scientific structuring of the environment in order to effect behavioral changes and to improve the psychological health and functioning of the individual. The goal of milieu therapy is to manipulate the environment so that all aspects of the client's hospital experience are considered therapeutic.

Group Therapy Leadership Styles

Laissez-Faire Leadership Style

A laissez-faire leadership style is demonstrated when the nurse leader sits silently and allows group members to stray from the assigned topic. This style allows group members to do as they please with no direction from the leader, often leading to frustration and confusion among the group members.

Democratic Leadership Style

A democratic leadership style is demonstrated when the nurse encourages clients to present unit problems and discuss possible solutions. Democratic leaders share information with group members and promote decision-

making by the members of the group, while providing guidance and expertise as needed.

Autocratic Leadership Style

An autocratic leadership style is demonstrated when decisions are mandated without consulting the group. Autocratic leadership increases productivity but often reduces morale and motivation due to the lack of member input and creativity.

Yalom's Curative Group Factors

Universality

Universality occurs when individuals realize that they are not alone in the problems, thoughts, and feelings they are experiencing. This realization reduces anxiety by the support and understanding of others.

Instillation of Hope

Instillation of hope occurs when members observe the progress of others in the group with similar problems and begin to believe that their own personal problems can also be resolved.

Imparting of Information

Imparting of information involves group members sharing knowledge gained through formal instruction as well as advice and suggestions.

Altruism

Altruism occurs when group members provide assistance and support to each other that creates a positive self-image and promotes self-growth. Individuals gain self-esteem through mutual caring and concern.

Group Roles

Aggressor

The aggressor expresses negativism and hostility toward others in the group or to the group leader and may use sarcasm in an effort to degrade the status of others.

Group Development Phases

Working Phase

During the working phase of group development, group members begin to look to each other instead of to the leader for guidance. Group members in the working phase begin to accept criticism from each other and use it constructively to create change.

Termination Phase

In the termination phase of group development, the group leader should help the members to process feelings of loss. The leader should encourage the members to review the goals and discuss outcomes, reminisce about what has occurred, and encourage members to provide feedback to each other about progress.

Self-Help Groups

Self-help groups, such as Alcoholics Anonymous (AA), are run by the members themselves, with leadership usually rotating among the members. Nurses may or may not be involved in self-help groups, which allow members to talk about feelings and reduce feelings of isolation, while receiving support from others undergoing similar experiences.

Optimal Group Therapy Configuration

The most optimal conditions for a therapeutic group include:

Closed membership Group size of 5 to 10 members Arranged in a circle of chairs

The focus of therapeutic groups is directed to relations within the group and the interactions among group members.

Group Leader's Role in Conflict Resolution

During group therapy, when members engage in a heated dispute, the role of the group leader is to encourage the group to solve the problem collectively. A democratic leadership style supports members in their participation and problem-solving, allowing the group to cooperatively address issues that relate to the group.

Termination Phase Challenges

In the termination phase of group development, the absence of the most faithful and participative group members may indicate that they are

experiencing problems with termination, leading to feelings of abandonment. Successful termination may help members develop skills to cope with future unrelated losses.

Nursing Roles and Responsibilities in Group

Therapy

Psychodrama Group

A psychiatric registered nurse is not qualified to lead a psychodrama group. Psychodrama is a specialized type of therapeutic group that must be led by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine and have received specialized training to become a psychodramatist.

Psychotherapy Group

A psychiatric registered nurse is not qualified to lead a psychotherapy group. Psychotherapy is a form of group therapy that must be led by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine.

Parenting Group

A psychiatric registered nurse is qualified to lead a parenting group. A parenting group can be classified as either a teaching group or a therapeutic group, which a psychiatric registered nurse is qualified to lead.

Family Therapy Group

A psychiatric registered nurse is not qualified to lead a family therapy group. Family therapy is a form of group therapy that must be led by qualified leaders who generally have advanced degrees in psychology, social work, nursing, or medicine.

Psychodrama Concepts

Psychodrama Provides a Safe Setting

Psychodrama provides a safe setting in which to discuss painful issues.

Psychodrama Protagonist

In psychodrama, the client plays the role of him or herself in a life-situation scenario and is called the protagonist.

Psychodrama Audience

In psychodrama, the client does not observe actor interactions from the audience. Other group members perform the role of the audience and discuss the situation they have observed, offer feedback, and express their feelings.

Psychodrama Facilitates Resolution

Psychodrama facilitates resolution of interpersonal conflicts.

Group Development Phases and Nurse's Role

Orientation Phase

During the orientation phase of group development, the nurse leader should work together with members to establish rules that will govern the group. The leader should ensure that group rules do not interfere with goal fulfillment and establish the need for and importance of confidentiality within the group. Members need to establish trust and cohesion in order to move into the working phase.

Working Phase

In the working phase, the role of the leader diminishes and becomes more one of facilitator. Some leadership functions are shared by certain members of the group as they progress toward resolution. The leader helps to resolve conflicts and continues to foster cohesiveness among the members, while ensuring that they do not deviate from the intended task or purpose for which the group was organized.

Termination Phase

In the termination phase, the leader encourages the group members to reminisce about what has occurred within the group, to review the goals and discuss the actual outcomes, and to encourage members to provide feedback to each other about individual progress within the group. The leader encourages members to discuss feelings of loss associated with termination of the group.

Definition of a Group

A group is a collection of individuals whose association is founded on shared commonalities of interest, values, norms, or purpose. Membership in a group is generally by chance (born into the group), by choice (voluntary affiliation), or by circumstance (the result of life-cycle events over which an individual may or may not have control).

Recovery Models in Mental Health

The Recovery Model

The recovery model is a framework for mental health care that emphasizes the individual's ability to live a self-directed life and reach their full potential, despite the challenges posed by mental illness. The Substance Abuse and Mental Health Services Administration (SAMHSA) defines recovery as "a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential."

Guiding Principles of the Recovery Model

According to SAMHSA, the guiding principles of the recovery model include:

Recovery emerges from hope. Recovery is person-driven. Recovery occurs via many pathways. Recovery is holistic. Recovery is supported by peers and allies. Recovery is supported through relationship and social networks. Recovery is culturally based and influenced. Recovery is supported by addressing trauma. Recovery involves individual, family, and community strengths and responsibility. Recovery is based on respect.

The Tidal Model of Recovery

The Tidal Model, developed by Barker and Buchanan-Barker, is another recovery-oriented approach that emphasizes the following 10 essential values, or "Tidal Commitments":

Value the Voice Respect the Language Develop Genuine Curiosity Become the Apprentice Use the Available Toolkit Craft the Step Beyond Give the Gift of Time Reveal Personal Wisdom Know that Change Is Constant Be Transparent

The Wellness Recovery Action Plan (WRAP)

The Wellness Recovery Action Plan (WRAP) is a self-management and recovery system designed to help individuals with mental health challenges monitor and manage their symptoms. The six steps of the WRAP model are:

Develop a Wellness Toolbox Create a Daily Maintenance List Identify Triggers Recognize Early Warning Signs Develop a Plan for When Things Are Breaking Down or Getting Worse Create a Crisis Plan

Examples and Applications

A client diagnosed with schizophrenia schedules follow-up appointments and group therapy, demonstrating the basic concept of the recovery model, which is empowerment of the consumer.

A nurse maintains a client's confidentiality, addresses the client appropriately, and does not discriminate based on gender, age, race, or religion, employing the guiding principle of the recovery model that "recovery is based on respect."

A nurse on an inpatient unit helps a client understand the significance of treatments and provides the client with copies of all documents related to the plan of care, employing the "Be Transparent" commitment of the Tidal Model of Recovery.

A client experiencing an exacerbation of psychiatric symptoms and threatening self-harm would require the implementation of the "Crisis Planning" step of the Wellness Recovery Action Plan (WRAP) model, where caregivers become decision-makers when the client can no longer care for themselves or keep themselves safe.

Recovery from Mental Health and Substance

Use Disorders

Definition of Recovery

Recovery from mental health disorders and substance use disorders is a process of change through which individuals improve their health and wellness, live a self-directed life, and strive to reach their full potential.