mental illness of schizophrenia

RN MENTAL HEALTH NURSING I

RN Mental Health Nursing REVIEW MODULE EDITION 11.0

Contributors Honey C. Holman, MSN, RN

Debborah Williams, MSN, RN

Sheryl Sommer, PhD, RN, CNE

Janean Johnson, MSN, RN, CNE

Brenda S. Ball, MEd, BSN, RN

Mendy G. McMichael, DNP, RN

Consultants Susan Adcock, RN, MS

Lisa Kongable, MA, ARNP, PMHCNS, CNE

Gail Raasakka, MSN, RN, CNE

Melanie P. Schrader, PhD, RN

INTELLECTUAL PROPERTY NOTICE ATI Nursing is a division of Assessment Technologies Institute®, LLC.

Copyright © 2019 Assessment Technologies Institute, LLC. All rights reserved.

The reproduction of this work in any electronic, mechanical or other means, now known or hereafter

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graphics, and text, are subject to trademark, service mark, trade dress, copyright, and/or other intellectual

property rights or licenses held by Assessment Technologies Institute, LLC, one of its affiliates, or by

third parties who have licensed their materials to Assessment Technologies Institute, LLC.

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II CONTENT MASTERY SERIES

IMPORTANT NOTICE TO THE READER Assessment Technologies Institute, LLC, is the publisher of this publication. The content of this publication is for

informational and educational purposes only and may be modified or updated by the publisher at any time. This

publication is not providing medical advice and is not intended to be a substitute for professional medical advice,

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subject matter covered; however, the publisher is not responsible for errors, omissions, or for any outcomes related to

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in this book may not be applicable to all people; likewise, some people may require a dose or experience a side effect

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drug, reading the package insert, and reviewing prescribing information for the most up-to-date recommendations

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in this book to procedures to be employed when rendering emergency care to the sick and injured are provided solely

as a general guide. Other or additional safety measures may be required under particular circumstances. This book

is not intended as a statement of the standards of care required in any particular situation, because circumstances

and a patient’s physical condition can vary widely from one emergency to another. Nor is it intended that this book

shall in any way advise personnel concerning legal authority to perform the activities or procedures discussed. Such

specific determination should be made only with the aid of legal counsel. Some images in this book feature models.

These models do not necessarily endorse, represent, or participate in the activities represented in the images. THE

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Director of content review: Kristen Lawler

Director of development: Derek Prater

Project management: Tiffany Pavlik, Shannon Tierney

Coordination of content review: Honey C. Holman, Debborah Williams

Copy editing: Kelly Von Lunen, Bethany Phillips, Kya Rodgers, Joshua Hoeven

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Cover design: Jason Buck

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RN MENTAL HEALTH NURSING USER’S GUIDE III

User’s Guide Welcome to the Assessment Technologies Institute® RN Mental Health Nursing Review Module Edition 11.0. The mission of ATI’s Content Mastery Series® Review Modules is to provide user-friendly compendiums of nursing knowledge that will: ● Help you locate important information quickly. ● Assist in your learning efforts. ● Provide exercises for applying your nursing knowledge. ● Facilitate your entry into the nursing profession as a

newly licensed nurse.

This newest edition of the Review Modules has been redesigned to optimize your learning experience. We’ve fit more content into less space and have done so in a way that will make it even easier for you to find and understand the information you need.

ORGANIZATION This Review Module is organized into units covering foundations for mental health nursing, traditional nonpharmacological therapies, psychobiologic disorders, psychopharmacological therapies, specific populations, and psychiatric emergencies. Chapters within these units conform to one of four organizing principles for presenting the content. ● Nursing concepts ● Procedures ● Disorders ● Medications

Nursing concepts chapters begin with an overview describing the central concept and its relevance to nursing. Subordinate themes are covered in outline form to demonstrate relationships and present the information in a clear, succinct manner.

Procedures chapters include an overview describing the procedure(s) covered in the chapter. These chapters provide nursing knowledge relevant to each procedure, including indications, nursing considerations, and complications.

Disorders chapters include an overview describing the disorder. These chapters cover assessments, including risk factors and expected findings, and patient-centered care, including nursing care, medications, therapeutic procedures, and interprofessional care.

Medications chapters include an overview describing a disorder or group of disorders. Medications used to treat these disorders are grouped according to classification. A specific medication can be selected as a prototype or example of the characteristics of medications in this classification. These sections include information about how the medication works and its therapeutic uses. Next, you will find information about complications, contraindications/precautions, and interactions, as well as nursing interventions and client education to help prevent and/or manage these issues. Finally, the chapter includes information on nursing administration of the medication and evaluation of the medication’s effectiveness.

ACTIVE LEARNING SCENARIOS AND APPLICATION EXERCISES

Each chapter includes opportunities for you to test your knowledge and to practice applying that knowledge. Active Learning Scenario exercises pose a nursing scenario and then direct you to use an ATI Active Learning Template (included at the back of this book) to record the important knowledge a nurse should apply to the scenario. An example is then provided to which you can compare your completed Active Learning Template. The Application Exercises include NCLEX-style questions, such as multiple-choice and multiple-select items, providing you with opportunities to practice answering the kinds of questions you might expect to see on ATI assessments or the NCLEX. After the Application Exercises, an answer key is provided, along with rationales.

NCLEX® CONNECTIONS To prepare for the NCLEX-RN, it is important to understand how the content in this Review Module is connected to the NCLEX-RN test plan. You can find information on the detailed test plan at the National Council of State Boards of Nursing’s website, www.ncsbn. org. When reviewing content in this Review Module, regularly ask yourself, “How does this content fit into the test plan, and what types of questions related to this content should I expect?”

To help you in this process, we’ve included NCLEX Connections at the beginning of each unit and with each question in the Application Exercises Answer Keys. The NCLEX Connections at the beginning of each unit point out areas of the detailed test plan that relate to the content within that unit. The NCLEX Connections attached to the Application Exercises Answer Keys demonstrate how each exercise fits within the detailed content outline. These NCLEX Connections will help you understand how the detailed content outline is organized, starting with major client needs categories and subcategories and followed by related content areas and tasks. The major client needs categories are:

● Safe and Effective Care Environment ◯ Management of Care ◯ Safety and Infection Control

● Health Promotion and Maintenance ● Psychosocial Integrity ● Physiological Integrity

◯ Basic Care and Comfort ◯ Pharmacological and Parenteral Therapies ◯ Reduction of Risk Potential ◯ Physiological Adaptation

An NCLEX Connection might, for example, alert you that content within a unit is related to: ● Psychosocial Integrity

◯ Behavioral Interventions ■ Incorporate behavioral management techniques

when caring for a client.

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IV USER’S GUIDE CONTENT MASTERY SERIES

QSEN COMPETENCIES As you use the Review Modules, you will note the integration of the Quality and Safety Education for Nurses (QSEN) competencies throughout the chapters. These competencies are integral components of the curriculum of many nursing programs in the United States and prepare you to provide safe, high-quality care as a newly licensed nurse. Icons appear to draw your attention to the six QSEN competencies.

Safety: The minimization of risk factors that could cause injury or harm while promoting quality care and maintaining a secure environment for clients, self, and others.

Patient-Centered Care: The provision of caring and compassionate, culturally sensitive care that addresses clients’ physiological, psychological, sociological, spiritual, and cultural needs, preferences, and values.

Evidence-Based Practice: The use of current knowledge from research and other credible sources, on which to base clinical judgment and client care.

Informatics: The use of information technology as a communication and information-gathering tool that supports clinical decision-making and scientifically based nursing practice.

Quality Improvement: Care related and organizational processes that involve the development and implementation of a plan to improve health care services and better meet clients’ needs.

Teamwork and Collaboration: The delivery of client care in partnership with multidisciplinary members of the health care team to achieve continuity of care and positive client outcomes.

ICONS Icons are used throughout the Review Module to draw your attention to particular areas. Keep an eye out for these icons.

This icon is used for NCLEX Connections.

This icon indicates gerontological considerations, or knowledge specific to the care of older adult clients.

This icon is used for content related to safety and is a QSEN competency. When you see this icon, take note of safety concerns or steps that nurses can take to ensure client safety and a safe environment.

This icon is a QSEN competency that indicates the importance of a holistic approach to providing care.

This icon, a QSEN competency, points out the integration of research into clinical practice.

This icon is a QSEN competency and highlights the use of information technology to support nursing practice.

This icon is used to focus on the QSEN competency of integrating planning processes to meet clients’ needs.

This icon highlights the QSEN competency of care delivery using an interprofessional approach.

This icon appears at the top-right of pages and indicates availability of an online media supplement, such as a graphic, animation, or video. If you have an electronic copy of the Review Module, this icon will appear alongside clickable links to media supplements. If you have a hard copy version of the Review Module, visit www.atitesting.com for details on how to access these features.

FEEDBACK ATI welcomes feedback regarding this Review Module. Please provide comments to comments@atitesting.com.

As needed updates to the Review Modules are identified, changes to the text are made for subsequent printings of the book and for subsequent releases of the electronic version. For the printed books, print runs are based on when existing stock is depleted. For the electronic versions, a number of factors influence the update schedule. As such, ATI encourages faculty and students to refer to the Review Module addendums for information on what updates have been made. These addendums, which are available in the Help/FAQs on the student site and the Resources/eBooks & Active Learning on the faculty site, are updated regularly and always include the most current information on updates to the Review Modules.

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RN MENTAL HEALTH NURSING TABLE OF CONTENTS V

Table of Contents

NCLEX® Connections 1

UNIT 1 Foundations for Mental Health Nursing 3 CHAPTER 1 Basic Mental Health Nursing Concepts 3

CHAPTER 2 Legal and Ethical Issues 9

CHAPTER 3 Effective Communication 15

CHAPTER 4 Stress and Defense Mechanisms 19

CHAPTER 5 Creating and Maintaining a Therapeutic and Safe Environment 25

CHAPTER 6 Diverse Practice Settings 31

NCLEX® Connections 35

UNIT 2 Traditional Nonpharmacological Therapies 37

CHAPTER 7 Psychoanalysis, Psychotherapy, and Behavioral Therapies 37

CHAPTER 8 Group and Family Therapy 41

CHAPTER 9 Stress Management 47

CHAPTER 10 Brain Stimulation Therapies 51

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VI TABLE OF CONTENTS CONTENT MASTERY SERIES

NCLEX® Connections 55

UNIT 3 Psychobiologic Disorders 57 CHAPTER 11 Anxiety Disorders 57

CHAPTER 12 Trauma- and Stressor-Related Disorders 61

CHAPTER 13 Depressive Disorders 67

CHAPTER 14 Bipolar Disorders 73

CHAPTER 15 Psychotic Disorders 77

CHAPTER 16 Personality Disorders 83

CHAPTER 17 Neurocognitive Disorders 87

CHAPTER 18 Substance Use and Addictive Disorders 93

CHAPTER 19 Eating Disorders 99

CHAPTER 20 Somatic Symptom and Related Disorders 105

NCLEX® Connections 111

UNIT 4 Psychopharmacological Therapies 113 CHAPTER 21 Medications for Anxiety and Trauma- and Stressor-Related Disorders 113

CHAPTER 22 Medications for Depressive Disorders 121

CHAPTER 23 Medications for Bipolar Disorders 129

CHAPTER 24 Medications for Psychotic Disorders 135

CHAPTER 25 Medications for Children and Adolescents Who Have Mental Health Issues 143

CHAPTER 26 Medications for Substance Use Disorders 153

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RN MENTAL HEALTH NURSING TABLE OF CONTENTS VII

NCLEX® Connections 159

UNIT 5 Specific Populations 161 CHAPTER 27 Care of Clients Who are Dying and/or Grieving 161

CHAPTER 28 Mental Health Issues of Children and Adolescents 165

NCLEX® Connections 171

UNIT 6 Psychiatric Emergencies 173 CHAPTER 29 Crisis Management 173

CHAPTER 30 Suicide 177

CHAPTER 31 Anger Management 181

CHAPTER 32 Family and Community Violence 185

CHAPTER 33 Sexual Assault 189

References 193

Active Learning Templates A1 Basic Concept A1

Diagnostic Procedure A3

Growth and Development A5

Medication A7

Nursing Skill A9

System Disorder A11

Therapeutic Procedure A13

Concept Analysis A15

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VIII TABLE OF CONTENTS CONTENT MASTERY SERIES

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RN MENTAL HEALTH NURSING NCLEX® CONNECTIONS 1

NCLEX® Connections

When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Management of Care CLIENT RIGHTS: Advocate for client rights and needs.

CONFIDENTIALITY/INFORMATION SECURITY: Maintain client confidentiality and privacy.

ESTABLISHING PRIORITIES: Apply knowledge of pathophysiology when establishing priorities for interventions with multiple clients.

ETHICAL PRACTICE: Practice in a manner consistent with a code of ethics for registered nurses.

LEGAL RIGHTS AND RESPONSIBILITIES Report client conditions as required by law.

Identify legal issues affecting the client.

REFERRALS: Identify community resources for the client.

Safety and Infection Control ACCIDENT/ERROR/INJURY PREVENTION: Identify factors that influence accident/injury prevention.

USE OF RESTRAINTS/SAFETY DEVICES: Monitor/evaluate the client’s response to restraints/safety device.

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2 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

Psychosocial Integrity COPING MECHANISMS: Assess client’s ability to adapt to temporary/permanent role changes.

CRISIS INTERVENTION: Assess potential for violence and use safety precautions.

MENTAL HEALTH CONCEPTS Recognize client use of defense mechanisms.

Assess client for alterations in mood, judgment, and, cognition.

THERAPEUTIC COMMUNICATION Assess verbal and nonverbal client communication needs.

Evaluate the effectiveness of communications with the client.

Use therapeutic communication techniques.

THERAPEUTIC ENVIRONMENT: Promote a therapeutic environment.

RN MENTAL HEALTH NURSING CHAPTER 1 BASIC MENTAL HEALTH NURSING CONCEPTS 3

UNIT 1 FOUNDATIONS FOR MENTAL HEALTH NURSING

CHAPTER 1 Basic Mental Health Nursing Concepts

Provision of care to clients in mental health settings is based on standards of care set by the American Nurses Association, the American Psychiatric Nurses Association, and the International Society of Psychiatric-Mental Health Nurses.

Nurses working in mental health settings should use the nursing process, as well as a holistic approach (biological, social, psychological, and spiritual aspects) to care for clients.

Nurses should use various methods to assess clients. These methods include observation, interviewing, physical examination, and collaboration.

ASSESSMENT ● Perform a physical assessment as indicated for client

condition or policy. ◯ Use touch to communicate caring as appropriate.

However, respect the client’s personal space if they do not wish to be touched.

◯ Be sure to include questions relating to difficulty sleeping, incontinence, falls or other injuries, depression, dizziness, and loss of energy.

◯ Include the family and significant others as appropriate. ◯ Obtain a detailed medication history. ◯ Following the interview, summarize and ask for

feedback from the client. ● Each encounter with a client involves an

ongoing assessment.

PSYCHOSOCIAL HISTORY ● Assess the client’s perception of own health, beliefs

about illness and wellness ● Activity/leisure activities, how the client passes time ● Assess the client’s use of substances and any history of

a substance use disorder ● Asses the client’s stress level and coping abilities: usual

coping strategies, support systems

Cultural beliefs and practices ● Assess the client’s cultural health care beliefs, practices,

and values. ● Assess for cultural factors that can impact the client’s care.

For example: Does the client’s diet consist of culture-specific foods? Does the client have specific beliefs or practices regarding health care? How is the client’s diagnosis viewed in their culture?

● The nurse’s awareness of culture alleviates stereotyping and stigmatizing.

● Use a trained interpreter when needed.

Spiritual and religious beliefs

Spiritual and religious beliefs affect the way in which a client finds meaning, hope, purpose, and a sense of peace.

● Spirituality refers to a client’s internal values, sense of morality, and how the client views the purpose of life. The client might not connect these spiritual views with religion.

● Religion refers to a client’s beliefs according to an organized set of patterns of worship and rituals.

● Assess the client’s support systems and assist the client to identify support persons and resources.

MENTAL STATUS EXAMINATION (MSE)

Level of consciousness

The level of consciousness is described using the following terms. Observed behaviors are included in the documentation.

Alert: The client is responsive and able to fully respond by opening their eyes and responding to a normal tone of voice and speech. The client answers questions spontaneously and appropriately.

Lethargic: The client is able to open their eyes and respond but is drowsy and falls asleep readily.

Stuporous: The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. The client might not be able to respond verbally.

Comatose: The client is unconscious and does not respond to painful stimuli.

● Abnormal posturing in the client who is comatose ◯ Decorticate rigidity: Flexion and internal rotation of upper-extremity joints and legs

◯ Decerebrate rigidity: Neck and elbow extension, wrist and finger flexion

Physical appearance

Examination includes assessment of personal hygiene, grooming, nutritional status, clothing choice, and whether the client looks older than their stated age. Expected findings with regard to this assessment are that the client is well-kempt, clean, and dressed appropriately for the given environment.

CHAPTER 1 Online Video: Mental Status Examination

4 CHAPTER 1 BASIC MENTAL HEALTH NURSING CONCEPTS CONTENT MASTERY SERIES

Behavior

Examination includes assessment of voluntary and involuntary body movements, and eye contact.

Mood: A client’s mood provides information about the emotion that the client is feeling.

Affect:� A client’s affect is an objective expression of mood (a flat affect or a lack of facial expression).

Cognitive and intellectual abilities ● Assess the client’s orientation to time, person, and place. ● Assess the client’s memory, both recent and remote.

◯ Immediate: Ask the client to repeat a series of numbers or a list of objects.

◯ Recent: Ask the client to recall recent events (visitors from the current day) or the purpose of the current mental health appointment or admission.

◯ Remote: Ask the client to state a fact from their past that is verifiable (their birth date or their mother’s maiden name).

● Assess the client’s level of knowledge. For example, ask the client what they know about their current illness or hospitalization.

● Assess the client’s ability to calculate. For example, can the client count backward from 100 in serials of 7?

● Assess the client’s ability to think abstractly. For example, can the client interpret a cliché (“A bird in the hand is worth two in the bush”)? The ability to interpret this demonstrates a higher-level thought process.

● Perform an objective assessment of the client’s perception of his illness.

● Assess the client’s judgment based on the client’s answer to a hypothetical question. For example, how would they answer the question, “What would you do if there were a fire in your room?” The client should provide a logical response.

● Assess the client’s rate and volume of speech, as well as the quality of their language. The client’s speech and responses should be meaningful, articulate, and appropriate.

STANDARDIZED SCREENING TOOLS There are a number of standardized rating scales that can be used for evaluation and monitoring of clients.

Mini-mental state examination (MMSE)

This examination is used to objectively assess a client’s cognitive status by evaluating the following. ● Orientation to time and place ● Attention span and ability to calculate by counting

backward by seven ● Registration and recalling of objects ● Language, including naming of objects, following of

commands, and ability to write

Pain assessment

Pain rating tools include visual analogue scales, Wong-Baker FACES Pain Rating Scale, the Faces Pain Scale-Revised, the McGill Pain Questionnaire (MPQ), and the Pain Assessment in Advanced Dementia (PAINAD) scale.

CONSIDERATIONS ACROSS THE LIFESPAN

Children and adolescents

Assessment includes temperament, social and environmental factors, cultural and religious concerns, and developmental level. The client should be the source of the information but with children and adolescents; caregivers can also provide valuable information.

● Mentally healthy children and adolescents trust others, view the world as safe, accurately interpret their environments, master developmental tasks, and use appropriate coping skills.

● Children and adolescents experience some of the same mental health problems as adults.

● Mental health and developmental disorders are not always easily diagnosed, potentially resulting in delayed or inadequate treatment interventions. Factors contributing to this include the following.

◯ Lack of the ability or necessary skills to describe what is happening

◯ A wide variation of “normal” behavior, especially in different developmental stages

● Assess for mood; anxiety; developmental, behavioral, and eating disorders; and risk for self-injury or suicide.

● Use the HEADSSS standardized assessment tool: ◯ Home environment: What is the client’s relationship like with their guardians and other family members living in the home?

◯ Education/employment: Is the client employed? How is the client’s school performance?

◯ Activities: Does the client participate in sports or other activities? How does the client interact with peers?

◯ Drug and substance use: Does the client use substances (alcohol, tobacco, or illicit drugs)?

◯ Sexuality: Has the client engaged in any sexual activity or had any sexual encounters?

◯ Suicide/depression: Is the client at risk for suicide or self-injury? Does the client have indications of depression?

◯ Safety: Is the client exposed to abuse in the home or violence in the neighborhood?

Older adults ● In addition to the aforementioned assessments, a

comprehensive assessment of the older adult client includes the following. ◯ Functional ability (the ability to independently get

dressed or manage household tasks) ◯ Economic and social status ◯ Environmental factors (stairways in the home) that

can affect the client’s well-being and lifestyle

RN MENTAL HEALTH NURSING CHAPTER 1 BASIC MENTAL HEALTH NURSING CONCEPTS 5

● Standardized assessment tools that are appropriate for the older adult population include the following.

◯ Geriatric Depression Scale (short form) ◯ Michigan Alcoholism Screening Test: Geriatric Version ◯ MMSE

● Conduct an assessment of all clients in the following manner.

◯ Use a private, quiet space with adequate lighting to accommodate for impaired vision and hearing.

◯ Make an introduction, and determine the client’s name preference.

◯ Stand or sit at the client’s level to conduct the interview, rather than standing over a client who is lying in bed or sitting in a chair.

MENTAL HEALTH DIAGNOSES ● The Diagnostic and Statistical Manual of Mental Disorders,

5th Edition (DSM-5), published by the American Psychiatric Association, is used by mental health professionals to diagnose mental health disorders in clients following standard criteria. It includes expected assessment findings for disorders and helps with planning, implementing, and evaluating care.

● Nurses use diagnoses from the North American Nursing Diagnosis Association (NANDA) to provide the basis of appropriate nursing interventions for clients.

SERIOUS MENTAL ILLNESS ● Includes disorders classified as severe and persistent

mental illnesses ● Clients often have difficulty with activities of daily

living (ADLs) ● Are lifelong disorders that can have remissions and

exacerbations

ROLE AND LIFE CHANGES ● Role transitions include loss of employment, divorce,

retirement, grand-parenthood, widowhood, death of guardian, and becoming a caregiver or recipient of care.

● Some role changes are predicted (an upcoming retirement). However, the client might find that others are unexpected (becoming the recipient of care due to a sudden illness or injury).

● Assessing the client’s ability to adapt and cope includes the following. ◯ Health status and functional abilities ◯ Living arrangements and employability ◯ Personality factors, such as attitudes ◯ Client, caregiver and family assessments ◯ Levels of information, such as community programs ◯ Medication use and supplemental services

● Evaluating whether client has successfully adapted includes the following. ◯ Able to state positive coping behaviors ◯ Able to identify maladaptive coping behaviors ◯ Able to participate in community resources ◯ Able to list stress reduction techniques ◯ Able to maintain housing and employment

THERAPEUTIC STRATEGIES IN THE MENTAL HEALTH SETTING

Counseling ● Using therapeutic communication skills ● Assisting with problem solving ● Crisis intervention ● Stress management

Milieu therapy ● Orienting the client to the physical setting ● Identifying rules and boundaries of the setting ● Ensuring a safe environment for the client ● Assisting the client to participate in

appropriate activities

Promotion of self-care activities ● Offering assistance with self-care tasks ● Allowing time for the client to complete self-care tasks ● Setting incentives to promote client self-care

Psychobiological interventions ● Administering prescribed medications ● Providing teaching to the client/family about medications ● Monitoring for adverse effects and effectiveness of

pharmacological therapy

Cognitive and behavioral therapies ● Modeling ● Operant conditioning ● Systematic desensitization

Health teaching: Teaching social and coping skills

Health promotion and health maintenance ● Assisting the client with cessation of smoking ● Monitoring other health conditions

Case management: Coordinating holistic care to include medical, mental health, and social services

6 CHAPTER 1 BASIC MENTAL HEALTH NURSING CONCEPTS CONTENT MASTERY SERIES

Application Exercises

1. A charge nurse is discussing mental status examinations with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching? (Select all that apply.)

A. “To assess cognitive ability, I should ask the client to count backward by sevens.”

B. “To assess affect, I should observe the client’s facial expression.”

C. “To assess language ability, I should instruct the client to write a sentence.”

D. “To assess remote memory, I should have the client repeat a list of objects.”

E. “To assess the client’s abstract thinking, I should ask the client to identify our most recent presidents.”

2. A nurse is planning care for a client who has a mental health disorder. Which of the following actions should the nurse include as a psychobiological intervention?

A. Assist the client with systematic desensitization therapy.

B. Teach the client appropriate coping mechanisms.

C. Assess the client for comorbid health conditions.

D. Monitor the client for adverse effects of medications.

3. A nurse in an outpatient mental health clinic is preparing to conduct an initial client interview. When conducting the interview, which of the following actions should the nurse identify as the priority?

A. Coordinate holistic care with social services.

B. Identify the client’s perception of their mental health status.

C. Include the client’s family in the interview.

D. Teach the client about their current mental health disorder.

4. A nurse is planning a peer group discussion about the Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5). Which of the following information is appropriate to include in the discussion? (Select all that apply.)

A. The DSM-5 includes client education handouts for mental health disorders.

B. The DSM-5 establishes diagnostic criteria for individual mental health disorders.

C. The DSM-5 indicates recommended pharmacological treatment for mental health disorders.

D. The DSM-5 assists nurses in planning care for client’s who have mental health disorders.

E. The DSM-5 indicates expected assessment findings of mental health disorders.

Active Learning Scenario

A nurse is admitting an older adult client who has depression to an acute mental health facility. Use the ATI Active Learning Template: Basic Concept to complete this item.

UNDERLYING PRINCIPLES ● Identify the standardized assessment tool the nurse should

use to assess the older adult client’s severity of depression. ● Identify at least four assessment/communication techniques

the nurse should use when assessing the older adult client.

NURSING INTERVENTIONS: Identify at least three factors the nurse should assess to determine if role and life changes are contributing to the client’s depression.

RN MENTAL HEALTH NURSING CHAPTER 1 BASIC MENTAL HEALTH NURSING CONCEPTS 7

Application Exercises Key

1. A. CORRECT: Counting backward by 7s is an appropriate technique to assess a client’s cognitive ability.

B. CORRECT: Observing a client’s facial expression is appropriate when assessing affect.

C. CORRECT: Writing a sentence is an indication of language ability.

D. Asking the client to repeat a list of objects is appropriate to assess immediate, rather than remote, memory.

E. Asking the client to identify recent presidents is appropriate to assess cognitive knowledge rather than abstract thinking.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

2. A. Assisting with systematic desensitization therapy is a cognitive and behavioral, rather than a psychobiological intervention.

B. Teaching appropriate coping mechanisms is a counseling or health teaching, rather than a psychobiological intervention.

C. Assessing for comorbid health conditions is health promotion and maintenance, rather than a psychobiological, intervention.

D. CORRECT: Monitoring for adverse effects of medications is an example of a psychobiological intervention.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

3. A. It is appropriate to coordinate holistic care for the client with social services as part of case management. However, another action is the priority.

B. CORRECT: Assessment is the priority action when using the nursing process approach to client care. Identifying the client’s perception of their mental health status provides important information about the client’s psychosocial history.

C. If the client wishes, it is appropriate to include the client’s family in the interview. However, another action is the priority.

D. It is appropriate to teach the client about their disorder. However, another action is the priority.

NCLEX® Connection: Health Promotion and Maintenance, Health Screening

4. A. The DSM-5 is used by mental health professionals. However, it does not include client education handouts.

B. CORRECT: The DSM-5 establishes diagnostic criteria for mental health disorders.

C. The DSM-5 does not indicate pharmacological treatment for mental health disorders.

D. CORRECT: Nurses use the DSM-5 to plan, implement, and evaluate care for client’s who have mental health disorders.

E. CORRECT: The DSM-5 identifies expected findings for mental health disorders.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES ● Standardized assessment tool for depression: Geriatric Depression Scale

● Assessment/communication techniques ◯ Use a private, quiet space with adequate lighting to accommodate for impaired vision and hearing.

◯ Make an introduction, and determine the client’s name preference. ◯ Stand or sit at the client’s level to conduct the interview. ◯ Use touch to communicate caring as appropriate. ◯ Include questions relating to difficulty sleeping, incontinence, falls or other injuries, depression, dizziness, and loss of energy.

◯ Include the family and significant others as appropriate. ◯ Obtain a detailed medication history. ◯ Following the interview, summarize and ask for feedback from the client.

NURSING INTERVENTIONS: Assessment of role and life changes ● Recent role transitions and whether they were expected or unexpected

● Client’s knowledge and use of positive coping behaviors ● Participation in community resources ● Client’s knowledge and use of stress reduction techniques ● Ability to maintain housing or employment

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

8 CHAPTER 1 BASIC MENTAL HEALTH NURSING CONCEPTS CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 2 LEGAL AND ETHICAL ISSUES 9

UNIT 1 FOUNDATIONS FOR MENTAL HEALTH NURSING

CHAPTER 2 Legal and Ethical Issues

A nurse who works in the mental health setting is responsible for practicing ethically, competently, safely, and in a manner consistent with all local, state, and federal laws.

Nurses must have an understanding of ethical principles and how they apply when providing care for clients in mental health settings.

Nurses are responsible for understanding and protecting client rights.

LEGAL RIGHTS OF CLIENTS IN THE MENTAL HEALTH SETTING

● Clients who have a mental health disorder diagnosis or who are receiving acute care for mental health disorder are guaranteed the same civil rights as any other citizen. These include the following. ◯ The right to humane treatment and care (medical and

dental care) ◯ The right to vote ◯ The rights related to granting, forfeiture, or denial of

a driver’s license ◯ The right to due process of law, including the right to

press legal charges against another person ● Clients also have various specific rights, including

the following. ◯ Informed consent and the right to refuse treatment ◯ Confidentiality ◯ A written plan of care/treatment that includes

discharge follow-up, as well as participation in the care plan and review of that plan

◯ Communication with people outside the mental health facility, including family members, attorneys, and other health care professionals

◯ Provision of adequate interpretive services if needed ◯ Care provided with respect, dignity, and

without discrimination ◯ Freedom from harm related to physical or

pharmacological restraint, seclusion, and any physical or mental abuse or neglect

◯ A psychiatric advance directive that includes the client’s treatment preferences in the event that an involuntary admission is necessary

◯ Provision of care with the least restrictive interventions necessary to meet the client’s needs without allowing them to be a threat to themselves or others

● Some legal issues regarding health care are decided in court using a specialized civil category called a tort. A tort is a wrongful act or injury committed by an entity or person against another person or another person’s property. Torts can be used to decide liability issues, as well as intentional issues that can involve criminal penalties (abuse of a client).

● State laws can vary greatly. The nurse is responsible for knowing specific laws regarding client care within the state or states in which the nurse practices.

ETHICAL ISSUES FOR CLIENTS IN THE MENTAL HEALTH SETTING

● In comparison to laws, statutes, and regulations (enacted by local, state, or federal government), ethical issues are philosophical ideas regarding right and wrong.

● Nurses are frequently confronted with ethical dilemmas regarding client care (bioethical issues).

● The nurse can also experience situations where there will be a conflict between two or more courses of action, known as an ethical dilemma. The nurse should respond to these situations using the bioethical principles.

● Because ethics are philosophical and involve values and morals, there is frequently no clear-cut, simple resolution to an ethical dilemma.

● The nurse must use ethical principles to decide ethical issues. These include the following:

Beneficence: The quality of doing good; can be described as charity

Example: A nurse helps a newly admitted client who has a psychotic disorder to feel safe in the environment of the mental health facility.

Autonomy: The client’s right to make their own decisions. However, the client must accept the consequences of those decisions. The client must also respect the decisions of others.

Example: Rather than giving advice to a client who has difficulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice.

Justice: Fair and equal treatment for all

Example: During a treatment team meeting, a nurse leads a discussion regarding whether or not two clients who broke the same facility rule were treated equally.

Fidelity: Loyalty and faithfulness to the client and to one’s duty

Example: A client asks a nurse to be present when they talk to their guardian for the first time in a year. The nurse remains with the client during this interaction.

Veracity: Honesty when dealing with a client

Example: A client states, “You and that other staff member were talking about me, weren’t you?” The nurse truthfully replies, “We were discussing ways to help you relate to the other clients in a more positive way.”

CHAPTER 2

10 CHAPTER 2 LEGAL AND ETHICAL ISSUES CONTENT MASTERY SERIES

CONFIDENTIALITY ● The client’s right to privacy is protected by the Health

Insurance Portability and Accountability Act (HIPAA) Privacy Rule of 2003.

● It is important to gain an understanding of the federal law and of state laws as they relate to confidentiality in specific health care facilities.

● The nurse should share information about the client, either verbal or written, only with those who are responsible for implementing the client’s treatment plan. The nurse should not discuss client information in public places, and social media should never be used to discuss clients or their information.

● Only if the client provides consent should the nurse share information with other persons not involved in the client treatment plan.

● Specific mental health issues where health care professionals can break confidentiality include the duty to warn and protect third parties, and the reporting of child and vulnerable adult abuse.

● If the nurse becomes aware that a client’s right to privacy is being violated, for example if a conversation in the elevator is overheard, they should immediately take action to stop the violation.

RESOURCES FOR SOLVING ETHICAL CLIENT ISSUES

● Code of Ethics for Nurses, found at the American Nurses Association’s website.

● Patient Care Partnership, found at the American Hospital Association’s website.

● The nurse practice act of a specific state ● Legal advice from attorneys ● Facility policies ● Other members of the health care team, including

facility bioethics committee (if available) ● Members of the clergy and other spiritual or

ethical counselors

TYPES OF ADMISSION TO A MENTAL HEALTH FACILITY

Informal admission: This is the least restrictive form of admission for treatment. The client does not pose a substantial threat to self or others. The client is free to leave the hospital at any time, even against medical advice.

Voluntary admission: The client or client’s guardian chooses admission to a mental health facility in order to obtain treatment. This client is considered competent and so has the right to refuse medication and treatment. Before release, a client can be evaluated, and if deemed necessary, the care provider can initiate an involuntary admission.

Temporary emergency admission: The client is admitted for emergent mental health care due to the inability to make decisions regarding care. The medical health care provider can initiate the admission which is then evaluated by a mental health care provider. The length of the temporary admission varies by the client’s need and state laws but often is not to exceed 15 days.

Involuntary admission: The client enters the mental health facility against their will for an indefinite period of time. The admission is based on the client’s need for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care. ● The criteria for an involuntary admission include

the following. ◯ Presence of mental illness ◯ Poses a danger to self or others ◯ Demonstrates severe disability or inability to meet

basic necessities including food, clothing, and shelter ◯ Requires treatment but unable to seek it voluntarily

related to the impact of the mental illness ● The number of physicians required to certify that the

client’s condition requires commitment varies from state to state (usually two). This can be imposed by a family member, legal guardian, primary care provider, or a mental health provider.

● The client can request a legal review of the admission at any time.

● An involuntary admission is limited to 60 days at which time a psychiatric and legal review of the admission is required.

● Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, including medication. The client who has been judged incompetent has a temporary or permanent guardian, usually a family member if possible, appointed by the court. The guardian can sign informed consent for the client. The guardian is expected to consider what the client would want if they were still competent.

Long-term involuntary admission: A type of admission that is similar to temporary commitment but must be imposed by the courts. Time of commitment varies, but is usually 60 to 180 days. Sometimes, there is no set release date.

CLIENT RIGHTS REGARDING SECLUSION AND RESTRAINT

● Nurses must know and follow federal/state/facility policies that govern the use of restraints.

● Use of seclusion rooms and/or restraints can be warranted and authorized for clients in some cases.

● Restraints are either physical or chemical (neuroleptic medication to calm the client).

● A client can voluntarily request a temporary timeout in cases in which the environment is disturbing or seems too stimulating. A timeout is different from prescribed seclusion because a timeout is by the request of the client.

RN MENTAL HEALTH NURSING CHAPTER 2 LEGAL AND ETHICAL ISSUES 11

● In general, the provider should prescribe seclusion and/or restraint for the shortest duration necessary, and only if less restrictive measures are not sufficient. They are for the physical protection of the client and/or the protection of other clients and staff.

● Less restrictive measures ◯ Verbal interventions (encouraging the client to calm down)

◯ Diversion or redirection ◯ Providing a calm, quiet environment ◯ Offering a PRN medication (though technically a chemical restraint, medications are considered less restrictive than a mechanical restraint)

● The nurse should never use seclusion or restraint for the following.

◯ Convenience of the staff ◯ Punishment of the client ◯ Clients who are extremely physically or mentally unstable

◯ Clients who cannot tolerate the decreased stimulation of a seclusion room

● When the nurse has tried all other less restrictive means to prevent a client from harming self or others, the following must occur in order to use seclusion or restraint.

◯ The provider must prescribe the seclusion or restraint in writing.

◯ Time limits for seclusion or restraints are based upon the age of the client.

■ Age 18 years and older: 4 hr ■ Age 9 to 17 years: 2 hr ■ Age 8 years and younger: 1 hr

◯ If the need for seclusion or restraint continues the provider must reassess the client and rewrite the prescription, specifying the type of restraint, every 24 hr or the frequency of time specified by facility policy.

◯ The facility protocol should identify the nursing responsibilities, including how often the client should be

■ Assessed (including for safety and physical needs), and the client’s behavior documented

■ Offered food and fluid ■ Toileted ■ Monitored for vital signs ■ Monitored for pain

◯ Complete documentation every 15 to 30 min (or according to facility policy) includes a description of the following.

■ Precipitating events and behavior of the client prior to seclusion or restraint

■ Alternative actions taken to avoid seclusion or restraint

■ The time treatment began ■ The client’s current behavior, what foods or fluids

were offered and taken, needs provided for, and vital signs

■ Medication administration ■ Time released from restraints

● The nurse can use seclusion or restraints without first obtaining a provider’s written prescription if it is an emergency situation. If this emergency treatment is initiated, the nurse must obtain the written prescription within a specified period of time (usually 15 to 30 min).

● Restraint or seclusion must be discontinued when the client is exhibiting behavior that is safer and quieter. Once restraints or seclusion are discontinued, the nurse must obtain a new prescription before initiating restraints again.

TORT LAW IN THE MENTAL HEALTH SETTING

A tort is referred to as a civil wrong doing, in which monetary damages can potentially be awarded to the plaintiff (injured party) and collected from the defendant (responsible party).

INTENTIONAL TORTS Intentional torts are willful actions that damage a client’s property or violate client rights. Although intentional torts can occur in any health care setting, they are particularly likely to occur in mental health settings due to the increased likelihood of violence and client behavior that can be challenging to facility staff.

False imprisonment: Confining a client to a specific area (a seclusion room) physically, verbally, or using a chemical restraint when it is not part of the clients treatment (i.e. to prevent client harm to self or others) is considered false imprisonment.

Assault: Making a threat to a client’s person (approaching the client in a threatening manner with a syringe in hand) is considered assault.

Battery: Touching a client in a harmful or offensive way is considered battery. This would occur if the nurse threatening the client with a syringe actually grabbed the client and gave an injection against the client’s will.

UNINTENTIONAL TORTS Unintentional torts are actions or inactions that cause unintended harm as a result of failing to meet one’s duty of care in either a personal or professional situation.

Negligence: Failing to provide adequate care in a personal or professional situation when one has an obligation to do so. To be liable for negligence, it must be proven that the professional had a duty to protect, breached the duty, that the action or failure to act caused injury (proximate cause) and that the injury would not have happened anyway (cause in fact), and that damages occurred.

Malpractice: A type of professional negligence.

12 CHAPTER 2 LEGAL AND ETHICAL ISSUES CONTENT MASTERY SERIES

DOCUMENTATION It is vital to clearly and objectively document information related to violent or other unusual episodes. The nurse should document the following.

Client behavior in a clear and objective manner

Example: The client suddenly began to run down the hall with both hands in the air, screaming obscenities.

Staff response� to disruptive, violent, or potentially harmful behavior (suicide threats or potential or actual harm to others), including timelines and the extent of response

Example: The client states, “I’m going to pound (other client) into the ground.” Client has picked up a chair and is standing 3 ft from other client with chair held over their head in both hands. Nurse calls for help. Client is immediately told by nurse,

“Put down the chair, and back away from (the other person).” Other client moved away to safe area. Five other staff members respond to verbal call for help within 30 seconds and stood several yards from client. Client then put the chair down, quietly turned around, walked to their room, and sat on the bed.

Time the nurse notified the provider� and any prescriptions received.

Active Learning Scenario

A nurse in a mental health facility is caring for an adult client who has bipolar disorder. The client becomes violent and begins throwing objects at other clients. After calling for assistance, what actions should the nurse take next? Use the ATI Active Learning Template: Basic Concept to complete this item.

NURSING INTERVENTIONS: Describe at least four actions the nurse can take to manage the client’s behavior before applying mechanical restraints. Include rationales for the actions.

Application Exercises

1. A nurse in an emergency mental health facility is caring for a group of clients. The nurse should identify that which of the following clients requires a temporary emergency admission?

A. A client who has schizophrenia with delusions of grandeur

B. A client who has manifestations of depression and attempted suicide a year ago

C. A client who has borderline personality disorder and assaulted a homeless man with a metal rod

D. A client who has bipolar disorder and paces quickly around the room while talking to themselves

2. A nurse decides to put a client who has a psychotic disorder in seclusion overnight because the unit is very short-staffed, and the client frequently fights with other clients. The nurse’s actions are an example of which of the following torts?

A. Invasion of privacy B. False imprisonment C. Assault D. Battery

3. A client tells a nurse, “Don’t tell anyone, but I hid a sharp knife under my mattress in order to protect myself from my roommate, who is always threatening me.” Which of the following actions should the nurse take?

A. Keep the client’s communication confidential, but talk to the client daily, using therapeutic communication to convince them to admit to hiding the knife.

B. Keep the client’s communication confidential, but watch the client and their roommate closely.

C. Tell the client that this must be reported to the health care team because it concerns the health and safety of the client and others.

D. Report the incident to the health care team, but do not inform the client of the intention to do so.

4. A nurse is caring for a client who is in mechanical restraints. Which of the following statements should the nurse include in the documentation? (Select all that apply.)

A. “Client ate most of their breakfast.” B. “Client was offered 8 oz of water every hr.” C. “Client shouted obscenities at assistive personnel.” D. “Client received chlorpromazine

15 mg by mouth at 1000.” E. “Client acted out after lunch.”

5. A nurse hears a newly licensed nurse discussing a client’s hallucinations in the hallway with another nurse. Which of the following actions should the nurse take first?

A. Notify the nurse manager. B. Tell the nurse to stop discussing the behavior. C. Provide an in-service program about confidentiality. D. Complete an incident report.

RN MENTAL HEALTH NURSING CHAPTER 2 LEGAL AND ETHICAL ISSUES 13

Application Exercises Key

1. A. The presence of delusions does not constitute a clear reason for a temporary emergency admission unless they present a danger for the client or others.

B. Clinical findings of depression do not constitute a clear reason for a temporary emergency admission unless the client is currently at risk for suicide.

C. CORRECT: A client who is a current danger to self or others is a candidate for a temporary emergency admission.

D. The presence of pacing does not constitute a clear reason for a temporary emergency admission.

NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

2. A. Invasion of privacy is the sharing or obtaining of the client’s confidential information without the client’s consent.

B. CORRECT: A civil wrong that violates a client’s civil rights is a tort. In this case, it is false imprisonment, which is the confining of a client to a specific area (a seclusion room) if the reason for such confinement is for the convenience of staff.

C. Assault is making a threat to the client’s person. D. Battery involves causing intentional, physical harm to clients.

NCLEX® Connection: Safety and Infection Control, Accident/ Error/Injury Prevention

3. A. Use therapeutic communication with the client. However, based on the nature of the information, the nurse cannot keep the information confidential from everyone despite the client’s request.

B. Based on the nature of the information, the nurse cannot keep the information confidential from everyone despite the client’s request.

C. CORRECT: The information presented by the client is a serious safety issue that the nurse must report to the health care team. Using the ethical principle of veracity, the student tells the client truthfully what must be done regarding the issue.

D. Inform the client if the information will be reported to the health care team.

NCLEX® Connection: Management of Care, Ethical Practice

4. A. Document objective information regarding intake in the client’s medical record (“the client at 70% of their breakfast”).

B. CORRECT: The amount and frequency of fluids offered is objective data that should be documented when caring for a client in mechanical restraints.

C. CORRECT: A description of the client’s verbal communication is objective data that should be documented when caring for a client in mechanical restraints.

D. CORRECT: The dosage and time of medication administration is objective data that should be documented when caring for a client in mechanical restraints

E. Document objective information regarding the client’s behavior in the client’s medical record.

NCLEX® Connection: Safety and Infection Control, Use of Restraints/Safety Devices

5. A. Notify the nurse manager if the client’s right to privacy is violated. However, there is another action to take first.

B. CORRECT: The greatest risk to this client is an invasion of privacy through the sharing of confidential information in a public place. The first action to take is to tell the newly licensed nurse to stop discussing the client’s hallucinations in a public location.

C. Provide an in-service program for staff about confidentiality. However, there is another action to take first.

D. Complete an incident report about the violation of the client’s right to privacy. However, there is another action to take first.

NCLEX® Connection: Management of Care, Confidentiality/ Information Security

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

NURSING INTERVENTIONS ● Tell the client calmly to sit down. Verbal intervention is the least restrictive method when dealing with an aggressive client.

● Provide the client with a decreased-stimulation environment and attempt diversion or redirection. These interventions are less restrictive than seclusion or restraint and the nurse should attempt these interventions prior to more restrictive actions.

● Offer the client a PRN medication (diazepam). It can be necessary for the nurse to administer diazepam to calm the client and is considered less restrictive than mechanical restraints.

● Place the client in a monitored seclusion room. It can become necessary to place the client in seclusion if the client persists in the behavior after attempting less restrictive interventions.

● If other interventions are unsuccessful, obtain a prescription for mechanical restraints. Follow facility policy for the application of restraints and the monitoring and documentation required for the client’s care.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

14 CHAPTER 2 LEGAL AND ETHICAL ISSUES CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 3 EFFECTIVE COMMUNICATION 15

UNIT 1 FOUNDATIONS FOR MENTAL HEALTH NURSING

CHAPTER 3 E‘ective Communication

Communication is a complex process of sending, receiving, and comprehending messages between two or more people. It is a dynamic and ongoing process that creates a unique experience between the participants.

Communicating effectively is a skill that the nurse develops. Nurses use communication when providing care to establish relationships, demonstrate caring, obtain information, and assist with changing behaviors. Foundational to the nurse-client relationship is therapeutic communication.

BASIC COMMUNICATION

BASIC LEVELS OF COMMUNICATION Intrapersonal communication: Communication that occurs within an individual. Also identified as “self-talk.” This occurs within one’s self and is the internal discussion that takes place when an individual is thinking thoughts and not outwardly verbalizing them. In nursing, intrapersonal communication allows nurses to perform a self-assessment of their values or beliefs prior to caring for a client whose diagnosis can trigger an emotional response.

Interpersonal communication: Communication that occurs one-on-one with another individual. In nursing, interpersonal communication is used when the nurse obtains a psychosocial history from a client or when listening to a client discuss their feelings.

Small-group communication: Communication that occurs between two or more people in a small group. In nursing, small-group communication allows the nurse to discuss a change in the client’s behavior with the health care team or discuss concerns with clients during a group therapy session.

Public communication: Communication that occurs within large groups of people. In nursing, this commonly occurs during educational endeavors where the nurse is teaching a large group of individuals. For example, the nurse can teach about suicide prevention with high school students at a school assembly.

Verbal communication

Vocabulary ● These are the words that are used to communicate either

a written or a spoken message. ● Limited vocabulary or speaking a language other

than English can make it difficult for the nurse to communicate with the client. Use of medical jargon can decrease client understanding.

Denotative/connotative meaning ● When communicating, participants must

share meanings. ● Words that have multiple meanings can cause

miscommunication if they are interpreted differently.

Clarity/brevity ● The shortest, simplest communication is usually

most effective. ● The client can have difficulty understanding

communication that is long and complex.

Timing/relevance ● Knowing when to communicate allows the receiver to be

more attentive to the message. ● Communicating with a client who is in pain or

distracted will make it difficult for the nurse to convey the message.

Pacing ● The rate of speech can communicate a meaning to

the receiver. ● Speaking rapidly can communicate the impression

that the nurse is in a rush and does not have time for the client.

Intonation ● The tone of voice can communicate a variety of feelings. ● The nurse can communicate feelings (acceptance,

judgment, and dislike) through tone of voice.

Nonverbal communication

Nurses should be aware of how they communicate nonverbally. The nurse should assess the client’s nonverbal communications for the meaning being conveyed, remembering that culture impacts interpretation. Nonverbal communication can have more impact on the message compared to the verbal words.

Attention to the following behaviors is important, as it is compared to the verbal message being conveyed.

● Appearance ● Posture ● Gait ● Facial expressions ● Eye contact ● Gestures ● Sounds ● Territoriality ● Personal space ● Silence

CHAPTER 3

16 CHAPTER 3 EFFECTIVE COMMUNICATION CONTENT MASTERY SERIES

THERAPEUTIC COMMUNICATION Therapeutic communication is the purposeful use of communication to build and maintain helping relationships with clients, families, and significant others. Therapeutic communication is essential when caring for a client who has a mental health disorder because of the emotional as well as the physical effects of the disorder on the client. ● The nurse uses interactive, purposeful

communication skills to ◯ Elicit and attend to the client’s thoughts, feelings,

concerns, and needs. ◯ Express empathy and genuine concern for the client’s

and family’s issues. ◯ Obtain information and give feedback about the

client’s condition. ◯ Intervene to promote functional behavior and

effective interpersonal relationships. ◯ Evaluate the client’s progress toward goals

and outcomes. ● Children and older adults frequently require adapted

techniques to enhance communication. ● Effective use of the nursing process depends

on therapeutic communication between the nurse, the client, the client’s family, and the interprofessional team.

CHARACTERISTICS ● Client centered: not social or reciprocal ● Purposeful, planned, and goal-directed

ESSENTIAL COMPONENTS Time

● Plan for and allow adequate time to communicate. ● Clients who have certain mental health disorders (major

depressive disorder or schizophrenia) can require a longer period of time to respond to questions.

Attending behaviors or active listening ● These are nonverbal means of conveying interest

in another. ● Eye contact typically conveys interest and respect but

varies by situation and culture. ● Body language and posture can demonstrate level of

comfort and ease. ● Vocal quality enhances rapport and emphasizes

particular topics or issues. ● Verbal tracking provides feedback by restating or

summarizing a client’s statements.

Caring attitude: Show concern and facilitate an emotional connection with the client and the client’s family.

Honesty: Be open, direct, truthful, and sincere.

Trust: Demonstrate reliability without doubt or question.

Empathy: Convey an objective awareness and understanding of the feelings, emotions, and behaviors of others, including trying to envision what it must be like to be in the position of the client and the client’s family.

Nonjudgmental attitude: This is a display of acceptance that will encourage open, honest communication.

NURSING PROCESS

ASSESSMENT ● Assess verbal and nonverbal communication needs. ● Identify any cultural considerations that can impact

communication (the use of eye contact or perception of personal space or touch).

● Assess for congruency between the verbal and nonverbal message.

● Consider the client’s developmental level and how communication should be adapted during the assessment phase.

CHILDREN ● Use simple, straightforward language. ● Be aware of own nonverbal messages, as children are

sensitive to nonverbal communication. ● Enhance communication by being at the child’s

eye level. ● Incorporate play in interactions. ● Be aware of the child’s level of development.

ADOLESCENTS ● Determine how the adolescent perceives the mental

health diagnosis. Is the adolescent at risk for refusal of treatment due to a desire to be “normal”?

● Identify if the mental health diagnosis affects the client’s relationship with her peers.

OLDER ADULT CLIENTS ● Recognize that the client might require amplification. ● Minimize distractions, and face the client

when speaking. ● Allow plenty of time for the client to respond. ● When impaired communication is assessed, ask for

input from caregivers or family to determine the extent of the deficits and how best to communicate.

PLANNING ● Minimize distractions. ● Provide for privacy. ● Identify mutually agreed-upon client outcomes. ● Set priorities according to the client’s needs. ● Plan for adequate time for interventions.

IMPLEMENTATION ● Establish a trusting nurse-client relationship. The client

feels more at ease during the implementation phase once a helping relationship is established.

● Provide empathetic responses and explanations to the client by using observations and providing hope, humor, and information.

● Manipulate the environment to decrease distractions.

Online Video: Therapeutic and Nontherapeutic Communication

RN MENTAL HEALTH NURSING CHAPTER 3 EFFECTIVE COMMUNICATION 17

EFFECTIVE COMMUNICATION SKILLS AND TECHNIQUES

Silence: Silence allows time for meaningful reflection.

Active listening: The nurse is able to hear, observe, and understand what the client communicates and to provide feedback.

Questions: Questions allow the nurse to obtain specific or additional information from the client. ● Open-ended questions: Facilitates spontaneous

responses and interactive discussion ● Closed-ended questions: Helpful if used sparingly

during the initial interaction to obtain specific data. Avoid using repeated closed-ended questions which can block further communication.

● Projective questions: Uses “what if” or similar questions to assist clients in exploring feelings and to gain greater understanding of problems and possible solutions

● Presupposition questions: Explores the client’s life goals or motivations by presenting a hypothetical situation in which the client no longer has the mental health disorder

Clarifying techniques: This technique is used to determine if the message received was accurate:

● Restating: Uses the client’s exact words. ● Reflecting: Directs the focus back to the client in order

for the client to examine his feelings. ● Paraphrasing: Restates the client’s feelings

and thoughts for the client to confirm what has been communicated.

● Exploring: Allows the nurse to gather more information regarding important topics mentioned by the client.

Offering�general�leads,�broad�opening�statements: This encourages the client to determine where the communication can start and to continue talking.

Showing acceptance and recognition: This technique acknowledges the nurse’s interest and nonjudgmental attitude.

Focusing: This technique helps the client to concentrate on what is important.

Giving information: This technique provides details that the client might need for decision making.

Presenting reality: This technique is used to help the client focus on what is actually happening and to dispel delusions, hallucinations, or faulty beliefs.

Summarizing: Summarizing emphasizes important points and reviews what has been discussed.

Offering�self: Use of this technique demonstrates a willingness to spend time with the client. Indicates to the client that the nurse has genuine concern.

Touch: If appropriate, therapeutic touch communicates caring and can provide comfort to the client.

BARRIERS TO EFFECTIVE COMMUNICATION

● Asking irrelevant personal questions ● Offering personal opinions ● Giving advice ● Giving false reassurance ● Minimizing feelings ● Changing the topic ● Asking “why” questions ● Offering value judgments ● Excessive questioning ● Giving approval or disapproval

Active Learning Scenario

A nurse in a mental health facility is preparing to conduct a class with older adult clients on grief and loss. Use the ATI Active Learning Template: Basic Concept to complete this item.

NURSING INTERVENTIONS: Describe at least four verbal or nonverbal communication interventions the nurse should employ when working with older adult clients.

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

NURSING INTERVENTIONS ● Recognize that the client might require amplification. ● Minimize distractions, and face the client when speaking. ● Allow plenty of time for the client to respond. ● When impaired communication is assessed, ask for input from caregivers or family to determine the extent of the deficits and how best to communicate.

● Provide for privacy.

NCLEX® Connection: Psychosocial Integrity, Grief and Loss

18 CHAPTER 3 EFFECTIVE COMMUNICATION CONTENT MASTERY SERIES

Application Exercises Key

1. A. Personal space is a component of nonverbal communication.

B. Posture is a component of nonverbal communication. C. Eye contact is a component of nonverbal communication. D. CORRECT: Identify intonation as a component of

verbal communication. Intonation is the tone of one’s voice and can communicate a variety of feelings.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

2. A. Offering general leads allows the nurse to take the direction of the discussion.

B. Summarizing enables the nurse to bring together important points of discussion to enhance understanding.

C. Focusing concentrates the attention on one single point. D. CORRECT: Restating allows the nurse to

repeat the main idea expressed.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

3. A. CORRECT: Offering advice to a client is a barrier to therapeutic communication that should be avoided. Advice tends to interfere with the client’s ability to make personal decisions and choices.

B. The technique of reflection directs the focus back to the client in order for the client to examine his feelings.

C. The skill of active listening is an important therapeutic technique to help hear and understand the information and messages the client is trying to convey.

D. Giving information informs the client of needed information to assist in the treatment planning process.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

4. A. The nurse’s discussion of client information with members of the health care team is an example of small-group communication.

B. The nurse’s self-assessment of feelings is an example of intrapersonal communication.

C. CORRECT: The nurse’s one-on-one communication with the client is an example of interpersonal communication.

D. The nurse’s educational presentation to a large group of adolescents is an example of public communication.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

5. A. This nontherapeutic response interjects the nurse’s opinion and can cause the caregiver to withhold their thoughts and feelings.

B. This nontherapeutic response interjects the nurse’s opinion and provides false reassurance which can cause the caregiver to withhold their thoughts and feelings.

C. This nontherapeutic response avoids addressing the caregiver’s concerns directly and indicates disinterest by the nurse for wanting to discuss the concerns with the parents.

D. CORRECT: This therapeutic response reflects upon, and accepts, the caregivers’ feelings, and it allows them to clarify what they are feeling.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

Application Exercises

1. A charge nurse is conducting a class on therapeutic communication with a group of newly licensed nurses. Which of the following aspects of communication should the nurse identify as a component of verbal communication?

A. Personal space

B. Posture

C. Eye contact

D. Intonation

2. A nurse in an acute mental health facility is communicating with a client. The client states, “I can’t sleep. I stay up all night.” The nurse responds, “You are having difficulty sleeping?” Which of the following therapeutic communication techniques is the nurse demonstrating?

A. Offering general leads

B. Summarizing

C. Focusing

D. Restating

3. A nurse is communicating with a client who was admitted for treatment of a substance use disorder. Which of the following communication techniques should the nurse identify as a barrier to therapeutic communication?

A. Offering advice

B. Reflecting

C. Listening attentively

D. Giving information

4. A nurse caring for a client who has anorexia nervosa. Which of the following examples demonstrates the nurse’s use of interpersonal communication?

A. The nurse discusses the client’s weight loss during a health care team meeting.

B. The nurse examines their own personal feelings about clients who have anorexia nervosa.

C. The nurse asks the client about personal body image perception.

D. The nurse presents an educational session about anorexia nervosa to a large group of adolescents.

5. A nurse is talking with the caregiver of a child who has demonstrated recent changes in behavior and mood. When the caregiver of the child asks the nurse for reassurance about their child’s condition, which of the following responses should the nurse make?

A. “I think your child is getting better. What have you noticed?”

B. “I’m sure everything will be okay. It just takes time to heal.”

C. “I’m not sure what’s wrong. Have you asked the doctor about your concerns?”

D. “I understand you’re concerned. Let’s discuss what concerns you specifically.”

RN MENTAL HEALTH NURSING CHAPTER 4 STRESS AND DEFENSE MECHANISMS 19

UNIT 1 FOUNDATIONS FOR MENTAL HEALTH NURSING

CHAPTER 4 Stress and Defense Mechanisms

Stress can result from a change in one’s environment that is threatening, causes challenges, or is perceived as damaging to that person’s well-being. Stress causes anxiety. Dysfunctional behavior can occur when a defense mechanism is used as a response to anxiety.

Individuals can use defense mechanisms as a way to manage conflict in response to anxiety. Defense mechanisms are reversible, and the client can use them in either an adaptive or maladaptive manner. Adaptive use of defense mechanisms helps people to achieve their goals in acceptable ways and reduce anxiety. Defense mechanisms become maladaptive when they interfere with functioning, relationships, and orientation to reality and are used in excess. It is important that the defense mechanism used is appropriate to the situation, and that an individual uses a variety of defense mechanisms, rather than having the same reaction to every stressful situation.

Defense mechanisms Altruism and sublimation are defense mechanisms that are always healthy. Other defense mechanisms can be used in a healthy manner. However, they can become maladaptive if used inappropriately or repetitively. Consider the frequency, intensity, and duration of use of the client’s defense mechanisms to determine whether they are adaptive or maladaptive.

Altruism

Dealing with anxiety by reaching out to others

ADAPTIVE USE: A nurse who lost a family member in a fire is a volunteer firefighter.

MALADAPTIVE USE: n/a

Sublimation

Dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression

ADAPTIVE USE: A person who has feelings of anger and hostility toward their work supervisor sublimates those feelings by working out vigorously at the gym during their lunch period.

MALADAPTIVE USE: n/a

Suppression

Voluntarily denying unpleasant thoughts and feelings

ADAPTIVE USE: A student puts off thinking about a fight they had with a friend so they can focus on a test.

MALADAPTIVE USE: A person who has lost their job states they will worry about paying bills next week.

Repression

Unconsciously putting unacceptable ideas, thoughts, and emotions out of awareness

ADAPTIVE USE: A person preparing to give a speech unconsciously forgets about the time when they were young and kids laughed at them while on stage.

MALADAPTIVE USE: A person who has a fear of the dentist continually forgets to go to their dental appointments.

Regression

Sudden use of childlike or primitive behaviors that do not correlate with the person’s current developmental level

ADAPTIVE USE: A young child temporarily wets the bed when they learn that their pet died.

MALADAPTIVE USE: A person who has a disagreement with a co-worker begins throwing things at their office.

Displacement

Shifting feelings related to an object, person, or situation to another less threatening object, person, or situation

ADAPTIVE USE: An adolescent angrily punches a punching bag after losing a game.

MALADAPTIVE USE: A person who is angry about losing their job destroys their child’s favorite toy.

Reaction formation

Unacceptable feelings or behaviors are controlled or kept out of awareness by overcompensating or demonstrating. Overcompensating or demonstrating the opposite behavior of what is felt.

ADAPTIVE USE: A person who is trying to quit smoking repeatedly talks to adolescents about the dangers of nicotine.

MALADAPTIVE USE: A person who resents having to care for an aging parent becomes overprotective and restricts their freedoms.

CHAPTER 4

20 CHAPTER 4 STRESS AND DEFENSE MECHANISMS CONTENT MASTERY SERIES

Undoing

Performing an act to make up for prior behavior (most commonly seen in children).

ADAPTIVE USE: An adolescent completes their chores without being prompted after having an argument with their parent.

MALADAPTIVE USE: An individual buys their significant other flowers and gifts after an incident of partner abuse.

Rationalization

Creating reasonable and acceptable explanations for unacceptable behavior

ADAPTIVE USE: An adolescent says, “They must already have a boyfriend” when rejected by a another adolescent.

MALADAPTIVE USE: A young adult explains they had to drive home from a party after drinking alcohol because they had to feed the dog.

Dissociation

A disruption in consciousness, memory, identity or perception of the environment that results in compartmentalization of uncomfortable or unpleasant aspects of oneself.

ADAPTIVE USE: A parent blocks out the distracting noise of their children in order to focus while driving in traffic.

MALADAPTIVE USE: A person forgets who they are following a sexual assault.

Denial

Pretending the truth is not reality to manage unpleasant, anxiety-causing thoughts or feelings.

ADAPTIVE USE: A person initially says, “No, that can’t be true” when told they have cancer.

MALADAPTIVE USE: A parent who is informed that their child was killed in combat tells everyone one month later that the child is coming home for the holidays.

Compensation

Emphasizing strengths to make up for weaknesses

ADAPTIVE USE: An adolescent who is physically unable to play contact sports excels in academic competitions.

MALADAPTIVE USE: A person who is shy learns computer skills to avoid socialization.

Identification

Conscious or unconscious assumption of the characteristics of another individual or group

ADAPTIVE USE: A child who has a chronic illness pretends to be a nurse for their dolls.

MALADAPTIVE USE: A child who observes their parent be abusive toward the other parent becomes a bully at school.

Intellectualization

Separation of emotions and logical facts when analyzing or coping with a situation or event

ADAPTIVE USE: A law enforcement officer blocks out the emotional aspect of a crime so they can objectively focus on the investigation.

MALADAPTIVE USE: A person who learns they have a terminal illness focuses on creating a will and financial matters rather than acknowledging their grief.

Conversion

Responding to stress through the unconscious development of physical manifestations not caused by a physical illness

ADAPTIVE USE: n/a

MALADAPTIVE USE: A person experiences deafness after their partner tells them that they want a divorce.

Splitting

Demonstrating an inability to reconcile negative and positive attributes of self or others into a cohesive image

ADAPTIVE USE: n/a

MALADAPTIVE USE: A client tells a nurse that the nurse is the only one who cares about them, yet the following day, the client refuses to talk to that nurse.

Projection

Attributing one’s unacceptable thoughts and feelings onto another who does not have them.

ADAPTIVE USE: n/a

MALADAPTIVE USE: A married client who is attracted to another person accuses their partner of having an extramarital affair.

RN MENTAL HEALTH NURSING CHAPTER 4 STRESS AND DEFENSE MECHANISMS 21

Anxiety Anxiety is viewed on a continuum with increasing levels of anxiety leading to decreasing ability to function.

Normal

A healthy life force that is necessary for survival, normal anxiety motivates people to take action.

For example, a potentially violent situation occurs on the mental health unit, and the nurse moves rapidly to defuse the situation. The anxiety experienced by the nurse during the situation helped him perform quickly and efficiently.

Acute (immediate state)

This level of anxiety is precipitated by an imminent loss or change that threatens one’s sense of security.

For example, the sudden death of a loved one precipitates an acute state of anxiety.

Chronic (sustained trait)

This level of anxiety is one that usually develops over time, often starting in childhood. The adult who experiences chronic anxiety might display that anxiety in physical manifestations (fatigue, frequent headaches).

ASSESSMENT Assessment of a client’s level of anxiety is basic to therapeutic intervention in any setting.

LEVELS OF ANXIETY

Mild ● Mild anxiety occurs in the normal experience of

everyday living. ● It increases one’s ability to perceive reality. ● There is an identifiable cause of the anxiety. ● Other characteristics include a vague feeling of mild

discomfort, restlessness, irritability, impatience, and apprehension.

● The client can exhibit mild tension-relieving behaviors (finger- or foot-tapping, fidgeting, lip-chewing).

Moderate ● Moderate anxiety occurs when mild anxiety escalates. ● Slightly reduced perception and processing of

information occurs, and selective inattention can occur. ● Ability to think clearly is hampered, but learning and

problem-solving can still occur. ● Other characteristics include concentration difficulties,

tiredness, pacing, change in voice pitch, voice tremors, shakiness, and increased heart rate and respiratory rate.

● The client can report somatic manifestations including headaches, backache, urinary urgency and frequency, and insomnia.

● The client who has this type of anxiety usually benefits from the direction of others.

Severe ● Perceptual field is greatly reduced with

distorted perceptions. ● Learning and problem-solving do not occur. ● Functioning is effective; behaviors are automatic. ● Other characteristics include confusion, feelings

of impending doom, hyperventilation, tachycardia, withdrawal, loud and rapid speech, and aimless activity.

● The client who has severe anxiety usually is not able to take direction from others.

Panic-level ● Panic-level anxiety is characterized by markedly

disturbed behavior. ● The client is not able to process what is occurring in the

environment and can lose touch with reality. ● The client experiences extreme fright and horror. ● The client experiences severe hyperactivity, flight, or

immobility ● Other characteristics can include dysfunction in speech,

dilated pupils, severe shakiness, severe withdrawal, inability to sleep, delusions, and hallucinations.

PATIENT-CENTERED CARE Nursing interventions are implemented according to the level of anxiety that a client is experiencing.

NURSING INTERVENTIONS

Mild to moderate anxiety

Use�active�listening�to�demonstrate�willingness�to�help,� and�use�specific�communication�techniques�(open‑ended� questions,�giving�broad�openings,�exploring,�and� seeking�clarification). THERAPEUTIC INTENT: Encourage the client to express feelings, develop trust, and identify the source of the anxiety.

Provide�a�calm�presence,�recognizing�the�client’s�distress. THERAPEUTIC INTENT: Assists the client to focus and to begin to problem solve.

Evaluate�past�coping�mechanisms. THERAPEUTIC INTENT: Assists the client to identify adaptive and maladaptive coping mechanisms.

Explore�alternatives�to�problem�situations. THERAPEUTIC INTENT: Offers options for problem-solving.

Encourage�participation�in�activities,�such�as�exercise� that�can�temporarily�relieve�feelings�of�inner�tension. THERAPEUTIC INTENT: Provides an outlet for pent-up tension, promotes endorphin release, and improves mental well-being.

22 CHAPTER 4 STRESS AND DEFENSE MECHANISMS CONTENT MASTERY SERIES

Severe to panic-level anxiety

Provide an environment that meets the physical and safety needs�of�the�client.�Remain�with�the�client�and�remain�calm. THERAPEUTIC INTENT: Minimizes risk to the client, who might be unaware of the need for basic things (fluids, food, sleep).

Provide a quiet environment with minimal stimulation. THERAPEUTIC INTENT: Helps to prevent intensification of the current level of anxiety.

Use�medications�and�restraint,�but�only�after�less�restrictive� interventions�have�failed�to�decrease�anxiety�to�safer�levels. THERAPEUTIC INTENT: Medications and/or restraint might be necessary to prevent harm to the client, other clients, and providers.

Encourage�gross�motor�activities,�such�as�walking�and� other�forms�of�exercise. THERAPEUTIC INTENT: Provides an outlet for pent-up tension, promotes endorphin release, and improves mental well-being.

Set�limits�by�using�firm,�short,�and�simple�statements.� Repetition�can�be�necessary.�Speak�slowly�and�in�a�low� pitched�voice. THERAPEUTIC INTENT: Can minimize risk to the client and providers. Clear, simple communication facilitates understanding.

Direct the client to acknowledge reality and focus on what�is�present�in�the�environment. THERAPEUTIC INTENT: Focusing on reality assists with reducing the client’s anxiety level.

Application Exercises

1. A nurse is caring for a client who smokes and has lung cancer. The client reports, “I’m coughing because I have that cold that everyone has been getting.” The nurse should identify that the client is using which of the following defense mechanisms?

A. Reaction formation

B. Denial

C. Displacement

D. Sublimation

2. A nurse is providing preoperative teaching for a client who was informed of the need for emergency surgery. The client has a respiratory rate 30/min, and says, “This is difficult to comprehend. I feel shaky and nervous.” The nurse should identify that the client is experiencing which of the following levels of anxiety?

A. Mild

B. Moderate

C. Severe

D. Panic

3. A nurse is caring for a client who is experiencing moderate anxiety. Which of the following actions should the nurse take when trying to give necessary information to the client? (Select all that apply.)

A. Reassure the client that everything will be okay.

B. Discuss prior use of coping mechanisms with the client.

C. Ignore the client’s anxiety so that she will not be embarrassed.

D. Demonstrate a calm manner while using simple and clear directions.

E. Gather information from the client using closed-ended questions.

Active Learning Scenario

A nurse is caring for a client who has severe anxiety. Use the ATI Active Learning Template: Basic Concept to complete this item.

NURSING INTERVENTIONS: Identify four nursing interventions that the nurse can use to assist the client who is experiencing severe anxiety.

RN MENTAL HEALTH NURSING CHAPTER 4 STRESS AND DEFENSE MECHANISMS 23

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

NURSING INTERVENTIONS ● Provide an environment that meets the physical and

safety needs of the client. Remain with the client. ● Provide a quiet environment with minimal stimulation. ● Use medications and restraint, but only after less restrictive

interventions have failed to decrease anxiety to safer levels. ● Encourage gross motor activities, such as

walking and other forms of exercise. ● Set limits by using firm, short, and simple

statements. Repetition may be necessary. ● Direct the client to acknowledge reality and focus

on what is present in the environment.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

Application Exercises Key

1. A. This is not an example of reaction formation, which is overcompensating or demonstrating the opposite behavior of what is felt.

B. CORRECT: This is an example of denial, which is pretending the truth is not reality to manage the anxiety of acknowledging what is real.

C. This is not an example of displacement, which is shifting feelings related to an object, person, or situation to another less threatening object, person, or situation.

D. This is not an example of sublimation, which is dealing with unacceptable feelings or impulses by unconsciously substituting acceptable forms of expression.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

2. A. In mild anxiety, the client’s ability to understand information may actually increase.

B. CORRECT: Moderate anxiety decreases problem-solving and may hamper the client’s ability to understand information. Vital signs may increase somewhat, and the client is visibly anxious.

C. Severe anxiety causes restlessness, decreased perception, and an inability to take direction.

D. During a panic attack, the person is completely distracted, unable to function, and may lose touch with reality.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

3. A. Providing false reassurance is an example of nontherapeutic communication.

B. CORRECT: Discussing the prior use of coping mechanisms assists the client in identifying ways of effectively coping with the current stressor.

C. Recognizing the client’s current level of anxiety assists the client to begin the process of problem solving.

D. CORRECT: Providing a calm presence assists the client in feeling secure and promotes relaxation. Clients experiencing moderate levels of anxiety often benefit from the direction of others.

E. Using open-ended questions for client communication encourages the client to express feelings and identify the source of the anxiety.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

24 CHAPTER 4 STRESS AND DEFENSE MECHANISMS CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 5 CREATING AND MAINTAINING A THERAPEUTIC AND SAFE ENVIRONMENT 25

UNIT 1 FOUNDATIONS FOR MENTAL HEALTH NURSING

CHAPTER 5 Creating and Maintaining a Therapeutic and Safe Environment

Therapeutic encounters can occur in any nursing setting if a nurse is sensitive to a client’s needs and uses effective communication skills.

The therapeutic nurse-client relationship is foundational to mental health nursing care.

The therapeutic nurse-client relationship differs from social and intimate relationships.

A therapeutic nurse-client relationship is:

• Purposeful and goal-directed.

• Well-defined with clear boundaries.

• Structured to meet the client’s needs.

• Characterized by an interpersonal process that is safe, confidential, reliable, and consistent.

MILIEU THERAPY Milieu therapy creates an environment that is supportive, therapeutic, and safe. (5.1) Milieu therapy can also be called therapeutic community or therapeutic environment.

● Management of the milieu refers to the management of the total environment of the mental health unit in order to provide the least amount of stress, while promoting the greatest benefit for all the clients.

● The goal is that while the client is in this therapeutic environment, the client will learn the tools necessary to cope adaptively, interact more effectively and appropriately, and strengthen relationship skills. The hope is that the client will use these tools in all other aspects of their life.

● The nurse, as manager of care, is responsible for structuring and/or implementing aspects of the therapeutic milieu within the mental health facility.

● One structure of the therapeutic milieu is regular community meetings, which include both the clients and the nursing staff.

THERAPEUTIC NURSE-CLIENT RELATIONSHIP

ROLES OF THE NURSE ● Consistently focus on the client’s

ideas, experiences, and feelings. ● Identify and explore the client’s needs and problems. ● Discuss problem-solving alternatives with the client. ● Help to develop the client’s strengths

and new coping skills. ● Encourage positive behavior change in the client. ● Assist the client to develop a sense of

autonomy and self-reliance. ● Portray genuineness, empathy, and a positive regard

toward the client. The nurse practices empathy by remaining nonjudgmental and attempting to understand the client’s actions and feelings. This differs from sympathy, in which the nurse allows oneself to feel the way the client does and is nontherapeutic.

CHAPTER 5

5.1 Characteristics of the therapeutic milieu

Physical setting Unit should be clean and orderly. The setting should include comfortable furniture placed so that it promotes interaction, solitary spaces for reading and thinking alone, comfortable places conducive to meals, and quiet areas for sleeping. Color scheme and overall design should be appropriate for the client’s age. Materials used for such features as floors should be attractive, easy to clean, and safe. Traffic-flow considerations should be conducive to client and staff movement.

Health care team member responsibilities Promote independence for self-care and individual growth in clients. Treat clients as individuals. Allow choices for clients within the daily routine and within individual treatment plans. Apply rules of fair treatment for all clients. Model good social behavior for clients, such as respect for the rights of others. Work cooperatively as a team to provide care. Maintain boundaries with clients. Maintain a professional appearance and demeanor. Promote safe and satisfying peer interactions among the clients. Practice open communication techniques with health team members and clients. Promote feelings of self-worth and hope for the future.

EMOTIONAL CLIMATE Clients should feel safe from harm (self-harm, as well as harm from the disruptive behaviors of other clients). Clients should feel cared for and accepted by the staff and others.

26 CHAPTER 5 CREATING AND MAINTAINING A THERAPEUTIC AND SAFE ENVIRONMENT CONTENT MASTERY SERIES

BENEFITS OF THE THERAPEUTIC RELATIONSHIP Therapeutic relationships contribute to the well-being of those who have a mental illness, as well as other clients, although the treatment goals will be individualized. (5.2) ● These relationships take time to establish, but even

time-limited therapeutic encounters can have positive outcomes.

● Therapeutic relationships have a positive impact on the success of treatment.

● Supervision by peers or the clinical team enhances the nurse’s ability to examine their own thoughts and feelings, maintain boundaries, and continue to learn from nurse-client relationships.

● Factors that positively affect the development of the therapeutic relationship include: ◯ NURSE FACTORS

■ Consistent approach to interaction ■ Adjustment of pace to client’s needs ■ Attentive listening ■ Positive initial impressions ■ Comfort level during the relationship ■ Self-awareness of own thoughts and feelings ■ Consistent availability

◯ CLIENT FACTORS ■ Trusting attitude ■ Willingness to talk ■ Active participation ■ Consistent availability

BOUNDARIES OF THE THERAPEUTIC RELATIONSHIP Boundaries must be established in order to maintain a safe and professional nurse-client relationship. ● Blurred boundaries occur if the relationship begins to meet

the needs of the nurse rather than those of the client, or if the relationship becomes social rather than therapeutic. ◯ Social relationship: Primary purpose is for

socialization or friendship with a focus on the mutual needs of the individuals involved in the relationship.

◯ Therapeutic relationship: Primary purpose is to identify the client’s problems or needs and then focus on assisting the client in meeting or resolving those issues.

The nurse must work to maintain a consistent level of involvement with the client, to reflect on boundary issues frequently, and to maintain awareness of how behaviors can be perceived by others (clients, family members, other health team members).

● Transference occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client’s personal life.

◯ BEHAVIORS ■ Client expects exclusive services from the nurse, such as extra session time

■ Client demonstrates jealousy of the nurse’s time or attention

■ Client compares the nurse to a former authority figure

◯ EXAMPLE: A client can see a nurse as being like their parent and thus can demonstrate some of the same behaviors with the nurse that they demonstrated with their parent.

◯ NURSING IMPLICATIONS: A nurse should be aware that transference by a client is more likely to occur with a person in authority.

● Countertransference occurs when a health care team member displaces characteristics of people in their past onto a client.

◯ BEHAVIORS ■ Nurse overly identifies with client ■ Nurse competes with client ■ Nurse argues with client

◯ EXAMPLE: A nurse can feel defensive and angry with a client for no apparent reason if the client reminds them of a friend who often elicited those feelings.

◯ NURSING IMPLICATIONS: A nurse should be aware that clients who induce very strong personal feelings can become objects of countertransference.

PHYSICAL SAFETY ● The nurses’ station and other areas should be placed to

allow for easy observation of clients by staff and access to staff by clients.

● Special safety features (bathroom bars and wheelchair accessibility for clients who are disabled) should be addressed.

● Set up the following provisions to prevent client self-harm or harm by others.

◯ No access to sharp or otherwise harmful objects ◯ Restriction of client access to restricted or locked areas

◯ Monitoring of visitors ◯ Restriction of alcohol and illegal substance access or use

◯ Restriction of sexual activity among clients ◯ Deterrence of elopement from facility ◯ Rapid de-escalation of disruptive and potentially violent behaviors through planned interventions by trained staff

● Seclusion rooms and restraints should be set up for safety and used only after all less-restrictive measures have been exhausted. When used, facility policies and procedures must be followed.

● Plan for safe access to recreational areas, occupational therapy, and meeting rooms.

● Teach fire, evacuation, and other safety rules to all staff. ◯ Provide clear plans for keeping clients and staff safe in emergencies.

◯ Maintain staff skills (cardiopulmonary resuscitation). ● Considerations of room assignments on a 24-hr care

unit should include: ◯ Personalities of each roommate. ◯ The likelihood of nighttime disruptions for a roommate if one client has difficulty sleeping.

◯ Mental health and medical diagnoses, such as how two clients who have severe paranoia might interact with each other.

RN MENTAL HEALTH NURSING CHAPTER 5 CREATING AND MAINTAINING A THERAPEUTIC AND SAFE ENVIRONMENT 27

ACTIVITIES WITHIN THE THERAPEUTIC MILIEU Activities are structured and include time for the following: ● Community meetings on the mental health unit should

enhance the emotional climate of the therapeutic milieu by promoting: ◯ Interaction and communication between staff

and clients. ◯ Decision making skills of clients. ◯ A feeling of self-worth among clients. ◯ Discussions of common unit objectives (encouraging

clients to meet treatment goals and plan for discharge).

◯ Discussion of issues of concern to all members of the unit, including common problems, future activities, and the introduction of new clients to the unit.

◯ Meetings can be structured so that they are client-led with decisions made by the group as a whole.

● Individual therapy is characterized by scheduled sessions with a mental health provider to address specific mental health concerns (depression).

● Group therapy is characterized by scheduled sessions for a group of clients to address common mental health issues (substance use disorder).

● Psychoeducational groups are based on clients’ level of functioning and personal needs (adverse effects of medication).

● Recreational activities include games and community outings.

● Unstructured, flexible time includes opportunities for the nurse and other staff to observe clients as they interact spontaneously within the milieu.

5.2 Phases and tasks of therapeutic relationships

Orientation NURSE Introduce self to the client and state purpose. Set the contract: meeting time, place, frequency, duration, and date of termination. Discuss confidentiality. Build trust by establishing expectations and boundaries. Set goals with the client. Explore the client’s ideas, issues, and needs. Explore the meaning of testing behaviors. Enforce limits on testing or other inappropriate behaviors.

CLIENT Meet with the nurse. Agree to the contract. Understand the limits of confidentiality. Understand the expectations and limits of the relationship. Participate in setting goals. Begin to explore own thoughts, experiences, and feelings. Explore the meaning of own behaviors.

Working NURSE Maintain relationship according to the contract. Perform ongoing assessment to plan and evaluate therapeutic measures. Facilitate the client’s expression of needs and issues. Encourage the client to problem-solve. Promote the client’s self-esteem. Foster positive behavioral change. Explore and deal with resistance and other defense mechanisms. Recognize transference and countertransference issues. Reassess the client’s problems and goals, and revise plans as necessary. Support the client’s adaptive alternatives and use of new coping skills. Remind the client about the date of termination.

CLIENT Explore problematic areas of life. Reconsider usual coping behaviors. Examine own world view and self-concept. Describe major conflicts and various defenses. Experience intense feelings and learn to cope with anxiety reactions. Test new behaviors. Begin to develop awareness of transference situations. Try alternative solutions.

Termination NURSE Provide opportunity for the client to discuss thoughts and feelings about termination and loss. Discuss the client’s previous experience with separations and loss. Elicit the client’s feelings about the therapeutic work in the nurse-client relationship. Summarize goals and achievements. Review memories of work in the sessions. Express own feelings about sessions to validate the experience with the client. Discuss ways for the client to incorporate new healthy behaviors into life. Maintain limits of final termination.

CLIENT Discuss thoughts and feelings about termination. Examine previous separation and loss experiences. Explore the meaning of the therapeutic relationship. Review goals and achievements. Discuss plans to continue new behaviors. Express any feelings of loss related to termination. Make plans for the future. Accept termination as final.

28 CHAPTER 5 CREATING AND MAINTAINING A THERAPEUTIC AND SAFE ENVIRONMENT CONTENT MASTERY SERIES

Application Exercises

1. A nurse is talking with a client who is at risk for suicide following their partner’s death. Which of the following statements should the nurse make?

A. “I feel very sorry for the loneliness you must be experiencing.”

B. “Suicide is not the appropriate way to cope with loss.”

C. “Losing someone close to you must be very upsetting.”

D. “I know how difficult it is to lose a loved one.”

2. A charge nurse is discussing the characteristics of a nurse-client relationship with a newly licensed nurse. Which of the following characteristics should the nurse include in the discussion? (Select all that apply.)

A. The needs of both participants are met.

B. An emotional commitment exists between the participants.

C. It is goal-directed.

D. Behavioral change is encouraged.

E. A termination date is established.

3. A nurse is in the working phase of a therapeutic relationship with a client who has methamphetamine use disorder. Which of the following actions indicates transference behavior?

A. The client asks the nurse if they will go out to dinner together.

B. The client accuses the nurse of being controlling just like an ex-partner.

C. The client reminds the nurse of a friend who died from substance toxicity.

D. The client becomes angry and threatens to engage in self harm.

4. A nurse is planning care for the termination phase of a nurse-client relationship. Which of the following actions should the nurse include in the plan of care?

A. Discussing ways to use new behaviors

B. Practicing new problem-solving skills

C. Developing goals

D. Establishing boundaries

5. A nurse is orienting a new client to a mental health unit. When explaining the unit’s community meetings, which of the following statements should the nurse make?

A. “You and a group of other clients will meet to discuss your treatment plans.”

B. “Community meetings have a specific agenda that is established by staff.”

C. “You and the other clients will meet with staff to discuss common problems.”

D. “Community meetings are an excellent opportunity to explore your personal mental health issues.”

Active Learning Scenario

A charge nurse is discussing the therapeutic milieu during the orientation of a newly hired nurse. Use the ATI Active Learning Template: Basic Concept to complete this item.

UNDERLYING PRINCIPLES: Identify at least five responsibilities of the health care team to maintain a therapeutic milieu.

NURSING INTERVENTIONS: Identify at least four interventions to prevent client self-harm or harm by others.

RN MENTAL HEALTH NURSING CHAPTER 5 CREATING AND MAINTAINING A THERAPEUTIC AND SAFE ENVIRONMENT 29

Application Exercises Key

1. A. This statement focuses on the nurse’s feelings and is sympathetic rather than empathetic.

B. This statement implies judgment and is therefore not an empathetic or therapeutic response.

C. CORRECT: This statement is an empathetic response that attempts to understand the client’s feelings.

D. This statement focuses on the nurse’s experiences rather than the client’s and is therefore not therapeutic.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

2. A. A therapeutic nurse-client relationship focuses on the needs of the client.

B. An emotional commitment between the participants is characteristic of an intimate or social relationship rather than one that is therapeutic.

C. CORRECT: A therapeutic nurse-client relationship is goal-directed.

D. CORRECT: A therapeutic nurse-client relationship encourages positive behavioral change.

E. CORRECT: A therapeutic nurse-client relationship has an established termination date.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Environment

3. A. This indicates the need to discuss boundaries but does not indicate transference.

B. CORRECT: When a client views the nurse as having characteristics of another person who has been significant to their personal life (an ex-partner) this indicates transference.

C. This indicates countertransference rather than transference. D. This indicates the need for safety intervention

but does not indicate transference.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Environment

4. A. CORRECT: Discussing ways for the client to incorporate new healthy behaviors into life is an appropriate task for the termination phase.

B. Practicing new problem-solving skills is an appropriate task for the working phase.

C. Developing goals is an appropriate task for the orientation phase.

D. Establishing boundaries is an appropriate task for the orientation phase.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

5. A. Individual treatment plans are discussed during individual therapy rather than a community meeting.

B. Community meetings may be structured so that they are client-led with decisions made by the group as a whole.

C. CORRECT: Community meetings are an opportunity for clients to discuss common problems or issues affecting all members of the unit.

D. Personal mental health issues are discussed during individual therapy rather than a community meeting.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Environment

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

UNDERLYING PRINCIPLES ● Promote independence for self-care and individual growth. ● Treat clients as individuals. ● Allow choices for clients within the daily routine and treatment plan. ● Apply rules of fair treatment for all clients. ● Model good social behavior. ● Work cooperatively as a team to provide care. ● Maintain boundaries with clients. ● Maintain a professional appearance and demeanor. ● Promote safe and satisfying peer interactions among clients. ● Practice open communication techniques with health team members and clients.

● Promote feelings of self-worth and hope for the future.

NURSING INTERVENTIONS ● Prevent access to sharp or harmful objects. ● Restrict client access to restricted or locked areas. ● Monitor visitors. ● Restrict alcohol and illegal substance access and use. ● Restrict sexual activity among clients. ● Deter elopement from facility. ● Provide rapid de-escalation of disruptive and potentially violent behaviors.

● Be aware of facility policies and procedures for seclusion or restraints. ● Provide safe access to recreational areas, therapy, and meeting rooms.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Environment

30 CHAPTER 5 CREATING AND MAINTAINING A THERAPEUTIC AND SAFE ENVIRONMENT CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 6 DIVERSE PRACTICE SETTINGS 31

UNIT 1 FOUNDATIONS FOR MENTAL HEALTH NURSING

CHAPTER 6 Diverse Practice Settings

Mental health nursing occurs in acute care and community settings, as well as in forensic nursing settings.

In all settings, nurses are advocates for clients who have mental illness. Referral of clients and their families to organizations and agencies that provide additional resources can provide significant support to individuals.

For example, the National Alliance on Mental Illness (NAMI), is a grassroots organization with the goals of improving the quality of life for persons with mental illness and providing research to better treat or eradicate mental illness. For more information, go to www . nami . org.

SETTINGS FOR MENTAL HEALTH CARE

ACUTE CARE This setting provides intensive treatment and supervision in locked units for clients who have severe mental illness, who present a danger to self or to others. ● Care in these facilities helps stabilize mental illness

manifestations and promotes the clients’ rapid return to the community.

● Staff is made up of an interprofessional team with management provided by nurses developing individualized plans that are client and family centered. Facilities might be privately owned or general hospitals, with payment provided by private funds or insurance.

● Facilities also might be state owned, with much of the funding provided for indigent clients. State-run facilities also often provide full-time acute care for forensic clients (those in a correctional setting) who have severe mental illness.

● Case management programs assist with client transition to a community setting after discharge from the acute care facility.

COMMUNITY Primary care is provided in community-based settings, which include clinics, schools and day-care centers, partial hospitalization programs, substance treatment facilities, forensic settings, psychosocial rehabilitation programs, telephone crisis counseling centers, and home health care. ● Nurses working in community care programs help to

stabilize or improve clients’ mental functioning within a community. They also teach, support, and make referrals in order to promote positive social activities.

● Nursing interventions in community settings provide for primary treatment as well as primary, secondary, and tertiary prevention of mental illness.

FORENSIC NURSING Forensic nursing is a combination of biophysical education and forensic science. It is the utilization of nursing science to public or legal proceedings. The registered nurses use scientific investigation, collection of evidence, analysis, prevention, and treatment of trauma and/or death of perpetrators and victims of violence, abuse, and traumatic accidents.

HISTORY OF MENTAL HEALTH CARE IN THE UNITED STATES

● Most clients who have severe mental illness were treated solely in acute care facilities before the middle of the twentieth century.

● Congress passed a series of acts in 1946, 1955, and 1963 in response to the appalling condition of facilities for the mentally ill. This began a trend to deinstitutionalize mental health care.

● Clients who had lived in acute care mental health facilities for many years were discharged into the community at a time when community mental health facilities were often unprepared to deal with this influx.

● The concept of case management was introduced around 1970 to meet the individual needs of clients in a mental health setting.

● Managed care through health maintenance organizations (HMOs), preferred provider organizations (PPOs), and others began limiting hospital stays for clients in a general medical setting starting around 1980.

● In 1999, mental illness determined to be a disability and with the Americans with Disabilities Act, those individuals with mental illnesses had a right to live in the community.

● Managed Behavioral Healthcare Organizations (MBHOs) later developed to coordinate care and limit stays in acute care facilities for clients needing mental health care.

● This began the trend to develop a continuum of acute care facilities and community mental health facilities to provide for all levels of behavioral health care needs.

● Complete and accurate documentation of client needs and progress by nurses and other health care professionals is needed to ensure quality care for each client.

CHAPTER 6

32 CHAPTER 6 DIVERSE PRACTICE SETTINGS CONTENT MASTERY SERIES

● Factors that will affect the future of mental health care include the following:

◯ An increase in the aging population ◯ An increase in cultural diversity within the United States ◯ The expansion of technology, which might provide new settings for client care, as well as new ways to treat mental illness more effectively

CLIENT CARE

ACUTE MENTAL HEALTH CARE SETTINGS ● Criteria to justify admission to an acute care

facility include: ◯ A clear risk of the client’s danger to self or others ◯ An inability to meet own basic needs ◯ Failure to meet expected outcomes of community-based treatment

◯ A dangerous decline in the mental health status of a client undergoing long-term treatment

◯ A client having a medical need in addition to a mental illness

● Goals of acute mental health treatment include the following:

◯ Prevention of the client harming self or others ◯ Stabilizing mental health crises ◯ Return of clients who are severally ill to some type of community care

Interprofessional team members ● Team members in acute care include nurses, mental

health technicians (who perform duties similar to assistive personnel in other health care facilities), psychologists, psychiatrists, other general health care providers, social workers, counselors, occupational and other specialty therapists, and pharmacists.

● The interprofessional team has the primary responsibility of planning and monitoring individualized treatment plans or clinical pathways of care, depending on the philosophy and policy of the facility.

● Plans for discharge to home or to a community facility begin from the time of admission and continue with the implementation of the initial treatment plan or clinical pathway.

Nursing role

Nurses in acute care mental health facilities use the nursing process and a holistic approach to provide care. Nursing roles include the following:

● Overall management of the unit, including client activities and therapeutic milieu

● Ensuring safe administration and monitoring of all client medications

● Implementation of individual client treatment plans, including client teaching

● Documentation of the nursing process for each client ● Managing crises as they arise

COMMUNITY HEALTH SETTINGS ● Nurses play a vital role in linking acute care facilities

with community care facilities. ● Intensive outpatient programs promote community

reintegration for clients.

Levels of prevention

Three levels of prevention are used by nurses when implementing community care interventions/teaching.

Primary prevention promotes health and emphasizes efforts on preventing mental health problems from occurring.

A nurse teaches a community education program on stress reduction techniques.

Secondary prevention focuses on early detection of mental illness.

A nurse screens older adults in the community for depression.

Tertiary prevention focuses on rehabilitation and prevention of further problems in clients who have previous diagnoses. Mental illness is present and with tertiary prevention, the goal is to prevent further deterioration or complications.

A nurse leads a support group for clients who have completed a substance use disorder program.

Community-based mental health programs

Community-based mental health programs are a continuum of mental health agencies with varying treatment intensity levels to allow clients to remain safe in the least restrictive environment possible.

Partial hospitalization programs ● These programs provide intense short-term treatment

for clients who are well enough to go home every night and who have a responsible person at home to provide support and a safe environment.

● Certain detoxification programs are a specialized form of partial hospitalization for clients who require medical supervision, stress management, substance use disorder counseling, and relapse prevention.

Assertive�community�treatment�(ACT) ● This includes nontraditional case management and

treatment by an interprofessional team for clients who have severe mental illness and are noncompliant with traditional treatment.

● ACT helps to reduce recurrences of hospitalizations and provides crisis intervention, assistance with independent living, and information regarding resources for necessary support services. ACT teams work with clients in their homes, in agencies, hospitals, and clinics.

Community mental health centers These facilities provide a variety of services for a wide range of community clients, including:

● Educational groups ● Medication dispensing programs ● Individual and family counseling programs

RN MENTAL HEALTH NURSING CHAPTER 6 DIVERSE PRACTICE SETTINGS 33

Psychosocial rehabilitation programs These programs provide a structured range of programs for clients in a mental health setting, including:

● Residential services ● Day programs for older adults

Home care: Home care provides mental health assessment, interventions, and family support in the client’s home. This is implemented most often for children, older adults, and clients who have medical conditions. With psychiatric home care, there are four criteria that must be met. The client must be homebound, have psychiatric diagnosis, need the skills of the mental health nurse and a plan of care developed by the health care provider.

ROLES OF NURSES IN DIVERSE MENTAL HEALTH PRACTICE SETTINGS

REGISTERED NURSE ● Educational preparation: diploma, associate degree,

or baccalaureate degree in nursing, with additional on-the-job training and continuing education in mental health care

● Can work in either an acute care or community-based facility

● Functions within a facility using the nursing process to provide care and treatment (medication)

● Manages care for a group of clients within a unit of the facility

ADVANCED PRACTICE NURSE ● Educational preparation: advanced nursing degree in

behavioral health (master’s degree, doctorate, nurse practitioner, or clinical nurse specialist)

● Can work independently, often supervising individuals or groups in either an acute care or community-based setting

● Can have prescription privileges and is able to independently recommend interventions

● Can manage and administrate the care for an entire facility

Active Learning Scenario

A nurse is conducting an education program regarding acute mental health treatment for a group of newly licensed nurses. What should the nurse include in this presentation? Use the ATI Active Learning Template: Basic Concept to complete this item.

RELATED CONTENT: Identify two criteria for admitting a client to a mental health facility.

UNDERLYING PRINCIPLES: Describe two concepts of mental health treatment.

NURSING INTERVENTIONS: Describe two interventions that apply to acute mental health care.

Application Exercises

1. A nurse is planning care for several clients who are attending community-based mental health programs. Which of the following clients should the nurse visit first?

A. A client who received a burn on the arm while using a hot iron at home

B. A client who requests a change of antipsychotic medication due to some new adverse effects

C. A client who reports hearing a voice saying that life is not worth living anymore

D. A client who tells the nurse about experiencing manifestations of severe anxiety before and during a job interview

2. A community mental health nurse is planning care to address the issue of depression among older adult clients in the community. Which of the following interventions should the nurse implement as a method of tertiary prevention?

A. Educating clients on health promotion techniques to reduce the risk of depression

B. Performing screenings for depression at community health programs

C. Establishing rehabilitation programs to decrease the effects of depression

D. Providing support groups for clients at risk for depression

3. A nurse is working in a community mental health facility. Which of the following services does this type of program provide? (Select all that apply.)

A. Educational groups B. Medication dispensing programs C. Individual counseling programs D. Detoxification programs E. Family therapy

4. A nurse in an acute mental health facility is assisting with discharge planning for a client who has a severe mental illness and requires supervision. The client’s partner works all day but is home by late afternoon. Which of the following strategies should the nurse suggest for follow-up care?

A. Receiving daily care from a home health aide B. Having a weekly visit from a nurse case worker C. Attending a partial hospitalization program D. Visiting a community mental health

center on a daily basis

5. A nurse is caring for a group of clients. Which of the following clients should a nurse consider for referral to an assertive community treatment (ACT) group?

A. A client in an acute care mental health facility who has fallen several times while running down the hallway

B. A client who lives at home and keeps “forgetting” to come in for a scheduled monthly antipsychotic injection for schizophrenia

C. A client in a day treatment program who reports increasing anxiety during group therapy

D. A client in a weekly grief support group who reports still missing a deceased partner who has been dead for 3 months

34 CHAPTER 6 DIVERSE PRACTICE SETTINGS CONTENT MASTERY SERIES

Application Exercises Key

1. A. This client has needs that should be met, but there is another client whom the nurse should see first.

B. This client has needs that should be met, but there is another client whom the nurse should see first.

C. CORRECT: A client who hears a voice saying life is not worth living anymore is at greatest risk for self-harm, and the nurse should visit this client first.

D. This client has needs that should be met, but there is another client whom the nurse should see first.

NCLEX® Connection: Management of Care, Establishing Priorities

2. A. This intervention is an example of primary prevention. B. This intervention is an example of secondary prevention. C. CORRECT: Rehabilitation programs are an example

of tertiary prevention. Tertiary prevention deals with prevention of further problems in clients already diagnosed with mental illness.

D. This intervention is an example of primary prevention.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

3. A. CORRECT: Educational groups are services provided in a community mental health facility.

B. CORRECT: Medication dispensing programs are services provided in a community mental health facility.

C. CORRECT: Individual counseling programs are services provided in a community mental health facility.

D. Detoxification programs are services provided in a partial hospitalization program.

E. CORRECT: Family therapy is a service provided in a community mental health facility.

NCLEX® Connection: Management of Care, Referrals

4. A. Daily care provided by a home health aide will not provide adequate supervision for this client.

B. Weekly visits from a case worker will not provide adequate care and supervision for this client.

C. CORRECT: A partial hospitalization program can provide treatment during the day while allowing the client to spend nights at home, as long as a responsible family member is present.

D. Daily visits to a community mental health center will not provide consistent supervision for this client.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

5. A. A client in acute care who has been running and falling should be helped by the treatment team on the client’s unit.

B. CORRECT: An ACT group works with clients who are nonadherent with traditional therapy (the client in a home setting who keeps “forgetting” a scheduled injection).

C. A client who has anxiety might be referred to a counselor or mental health provider.

D. A client who is grieving for a deceased partner who died 3 months ago is currently involved in an appropriate intervention.

NCLEX® Connection: Management of Care, Referrals

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT ● Clear risk of the client’s danger to self and others. ● Failure to meet expected outcomes of community-based treatment. ● A dangerous decline in the mental health status of a client undergoing long-term treatment

● A client having a medical need in addition to a mental illness.

UNDERLYING PRINCIPLES ● Goals of acute mental health treatment:

◯ Prevention of the client harming self or others ◯ Stabilizing mental health crises ◯ Return of clients who are severally ill to some type of community care

● Interprofessional team members in acute care include nurses, mental health technicians, psychologists, psychiatrists, other general health care providers, social workers, counselors, occupational and other specialty therapists, and pharmacists.

NURSING INTERVENTIONS ● Who: The interprofessional team member’s primary responsibility is planning and monitoring individualized treatment plans or clinical pathways of care.

● When: Plans for discharge to home or to a community facility begin from the time of admission.

● How: Nursing roles include overall management of the unit, including client activities and therapeutic milieu.

● Ensuring safe administration and monitoring of client medications. ● Implementation of individual client treatment plans, including client teaching.

● Documentation of the nursing process for each client. Manage crises as they arise.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

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RN MENTAL HEALTH NURSING NCLEX® CONNECTIONS 35

NCLEX® Connections

When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Psychosocial Integrity BEHAVIORAL INTERVENTIONS Participate in group sessions.

Assist client to develop and use strategies to decrease anxiety

FAMILY DYNAMICS Assess family dynamics to determine plan of care.

Encourage the client’s participation in group/family therapy.

Evaluate resources available to assist family functioning.

MENTAL HEALTH CONCEPTS: Apply knowledge of client psychopathology to mental health concepts applied in individual/group/family therapy.

STRESS MANAGEMENT Assess stressors, including environmental, that affect client care.

Provide information to client on stress management techniques.

SUPPORT SYSTEMS: Encourage the client’s involvement in the health care decision-making process.

Reduction of Risk Potential POTENTIAL FOR COMPLICATIONS OF DIAGNOSTIC TESTS/TREATMENTS/PROCEDURES Provide care for client undergoing electroconvulsive therapy.

Use precautions to prevent injury and/or complications associated with a procedure or diagnosis.

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36 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 7 PSYCHOANALYSIS, PSYCHOTHERAPY, AND BEHAVIORAL THERAPIES 37

UNIT 2 TRADITIONAL NONPHARMACOLOGICAL THERAPIES

CHAPTER 7 Psychoanalysis, Psychotherapy, and Behavioral Therapies

Psychoanalysis, psychotherapy, and behavioral therapies are approaches to addressing mental health issues using various methods and theoretical bases.

Nurses working in mental health settings need to be familiar with the methods that are part of these approaches and their application in practice.

PSYCHOANALYSIS Classical psychoanalysis is a therapeutic process of assessing unconscious thoughts and feelings, and resolving conflict by talking to a psychoanalyst. Clients attend many sessions over the course of months to years.

● Due to the length of psychoanalytic therapy and health insurance constraints, classical psychoanalysis is unlikely to be the sole therapy of choice.

● Psychoanalysis was first developed by Sigmund Freud to resolve internal conflicts which, he contended, always occur from early childhood experiences. Psychoanalysis, as developed by Freud, is seldom used today.

● Past relationships are a common focus for therapy and to uncover unconscious conflicts.

Transference, which includes feelings that the client has developed toward the therapist in relation to similar feelings toward significant persons in the client’s early childhood

Countertransference, the unconscious feelings that the healthcare worker has toward the client. The client can remind them of a person from their past in a positive or negative manner.

THERAPEUTIC TOOLS Free association, which is the spontaneous, uncensored verbalization of whatever comes to a client’s mind

Dream analysis and interpretation, believed by Freud to be urges and impulses of the unconscious mind that played out through the dreams of clients

Use of defense mechanisms

PSYCHOTHERAPY Psychotherapy involves more verbal therapist-to-client interaction than classic psychoanalysis. The client and the therapist develop a trusting relationship to explore the client’s problems.

Psychodynamic psychotherapy employs the same tools as psychoanalysis, but it focuses more on the client’s present state, rather than their early life. This type of therapy tends to last longer than other treatment approaches.

Interpersonal�psychotherapy�(IPT)� assists clients in addressing specific problems. It can improve interpersonal relationships, communication, role-relationship, and bereavement. The premise with interpersonal therapy is that many mental health disorders are influenced by interpersonal interactions and the social context. The goal is to improve interpersonal and social functioning which will reduce the psychiatric manifestations.

Cognitive therapy is based on the cognitive model, which focuses on individual thoughts and behaviors to solve current problems. The belief is that thoughts come before feelings and actions. It treats depression, anxiety, eating disorders, and other issues that can improve by changing a client’s attitude toward life experiences.

Behavioral therapy ● In protest of Freud’s psychoanalytic theory, behavioral

theorists (Ivan Pavlov, John B. Watson, and B.F. Skinner) felt that changing behavior was the key to treating problems (anxiety or depressive disorders).

● Behavioral therapy is based on the theory that behavior is learned and has consequences. Abnormal behavior results from an attempt to avoid painful feelings. Changing abnormal or maladaptive behavior can occur without the need for insight into the underlying cause of the behavior.

● Behavioral therapies teach clients ways to decrease anxiety or avoidant behavior and give clients an opportunity to practice techniques. Behavioral therapy teaches activities to help the client reduce anxious and avoidant behavior like relaxation training and modeling.

● Behavioral therapy has been used successfully to treat clients who have phobias, substance use or addictive disorders, and other issues.

Cognitive-behavioral therapy uses both cognitive and behavioral approaches to assist a client with anxiety management. This therapy takes into account what clients think influences their feelings and behaviors.

Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior. This therapy focuses on gradual behavior changes and provides acceptance and validation for these clients.

CHAPTER 7

38 CHAPTER 7 PSYCHOANALYSIS, PSYCHOTHERAPY, AND BEHAVIORAL THERAPIES CONTENT MASTERY SERIES

USE OF COGNITIVE THERAPY

Cognitive reframing

Changing cognitive distortions can decrease anxiety. Cognitive reframing assists clients to identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk. For example, a client who has a depressive disorder might say they are “a bad person” who has “never done anything good” in their life. Through therapy, this client can change their thinking to realize that they might have made some bad choices, but that they are not “a bad person.”

Priority restructuring: Assists clients to identify what requires priority (devoting energy to pleasurable activities).

Journal keeping: Helps clients write down stressful thoughts and has a positive effect on well-being.

Assertiveness training: Teaches clients to express feelings, and solve problems in a nonaggressive manner.

Monitoring thoughts: Helps clients to be aware of negative thinking.

TYPES AND USES OF BEHAVIORAL THERAPY

Modeling

A therapist or others serve as role models for a client, who imitates this modeling to improve behavior.

USE IN MENTAL HEALTH NURSING: Modeling can occur in the acute care milieu to help clients improve interpersonal skills. The therapist demonstrates appropriate behavior in a stressful situation with the goal of having the client imitate the behavior.

Operant conditioning

The client receives positive rewards for positive behavior (positive reinforcement).

USE IN MENTAL HEALTH NURSING: As an example: a client receives tokens for good behavior, and he can exchange them for a privilege or other items.

Systematic desensitization

This therapy is the planned, progressive, or graduated exposure to anxiety-provoking stimuli in real-life situations, or by imagining events that cause anxiety. During exposure, the client uses relaxation techniques to suppress anxiety response.

USE IN MENTAL HEALTH NURSING: Systematic desensitization begins with the client mastering relaxation techniques. Then, the client is exposed to increasing levels of the anxiety-producing stimulus (either imagined or real) and uses relaxation to overcome anxiety. The client is then able to tolerate a greater and greater level of the stimulus until anxiety no longer interferes with functioning. Used to assist clients who have phobias that are anxiety producing.

Aversion therapy

Pairing of a maladaptive behavior with a punishment or unpleasant stimuli to promote a change in the behavior.

USE IN MENTAL HEALTH NURSING: A therapist or treatment team can use unpleasant stimuli (bitter taste, mild electric shock), as punishment for behaviors (alcohol use disorder, violence, self-mutilation, and thumb-sucking). With aversion therapy, ongoing supervision and evaluation is essential for those administering the aversion therapy.

Meditation, guided imagery, diaphragmatic breathing, muscle relaxation, and biofeedback

This therapy uses various techniques to control pain, tension, and anxiety.

USE IN MENTAL HEALTH NURSING: A nurse can teach diaphragmatic breathing to a client having a panic attack, or to a female client in labor.

OTHER TECHNIQUES Flooding: Exposing a client, while in the company of a therapist, to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response

Response prevention: Preventing a client from performing a compulsive behavior with the intent that anxiety will diminish

Thought stopping: Teaching a client, when negative thoughts or compulsive behaviors arise, to say or shout,

“stop,” and substitute a positive thought. The goal over time is for the client to use the command silently.

Validation therapy: Useful for clients with neurocognitive disorders. It is a process of communication with a disoriented older adult client by respecting and validating their feelings in a time or place that is real to them, even though it does not relate to actual reality.

RN MENTAL HEALTH NURSING CHAPTER 7 PSYCHOANALYSIS, PSYCHOTHERAPY, AND BEHAVIORAL THERAPIES 39

Active Learning Scenario

A nurse working in an acute mental health unit is caring for a client who has a personality disorder. The client refuses to attend group meetings and will not speak to other clients or attend unit activities. The client enjoys visiting with staff and requests daily to take a walk outside with a staff member. The provider prescribes behavioral therapy with operant conditioning. Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.

DESCRIPTION OF PROCEDURE: Discuss behavioral therapy and operant conditioning.

OUTCOMES/EVALUATION: Identify an appropriate client outcome.

NURSING INTERVENTIONS: Identify an appropriate nursing action to implement operant conditioning with this client.

Application Exercises

1. A nurse is teaching a client who has an anxiety disorder and is scheduled to begin classical psychoanalysis. Which of the following client statements indicates an understanding of this form of therapy?

A. “Even if my anxiety improves, I will need to continue this therapy for 6 weeks.”

B. “The therapist will focus on my past relationships during our sessions.”

C. “Psychoanalysis will help me reduce my anxiety by changing my behaviors.”

D. “This therapy will address my conscious feelings about stressful experiences.”

2. A nurse is discussing free association as a therapeutic tool with a client who has major depressive disorder. Which of the following client statements indicates understanding of this technique?

A. “I will write down my dreams as soon as I wake up.” B. “I might begin to associate my therapist

with important people in my life.” C. “I can learn to express myself in

a nonaggressive manner.” D. “I should say the first thing that comes to my mind.”

3. A nurse is preparing to implement cognitive reframing techniques for a client who has an anxiety disorder. Which of the following techniques should the nurse include in the plan of care? (Select all that apply.)

A. Priority restructuring B. Monitoring thoughts C. Diaphragmatic breathing D. Journal keeping E. Meditation

4. A nurse is caring for a client who has a new prescription for disulfiram for treatment of alcohol use disorder. The nurse informs the client that this medication can cause nausea and vomiting when alcohol is consumed. Which of the following types of treatment is this method an example?

A. Aversion therapy B. Flooding C. Biofeedback D. Dialectical behavior therapy

5. A nurse is assisting with systematic desensitization for a client who has an extreme fear of elevators. Which of the following actions should the nurse implement with this form of therapy?

A. Demonstrate riding in an elevator, and then ask the client to imitate the behavior.

B. Advise the client to say “stop” out loud every time they begin to feel an anxiety response related to an elevator.

C. Gradually expose the client to an elevator while practicing relaxation techniques.

D. Stay with the client in an elevator until the anxiety response diminishes.

40 CHAPTER 7 PSYCHOANALYSIS, PSYCHOTHERAPY, AND BEHAVIORAL THERAPIES CONTENT MASTERY SERIES

Application Exercises Key

1. A. Classical psychoanalysis is a therapeutic process that requires many sessions over months to years.

B. CORRECT: Classical psychoanalysis places a common focus on past relationships to identify the cause of the anxiety disorder.

C. Classical psychoanalysis focuses on identifying and resolving the cause of the anxiety rather than changing behavior.

D. Classical psychoanalysis assesses unconscious, rather than conscious, thoughts and feelings.

NCLEX® Connection: Physiological Adaptation, Illness Management

2. A. Dream analysis and interpretation are therapeutic tools. However, they are not an example of free association.

B. Associating the therapist with significant persons in the client’s life is an example of transference rather than free association.

C. Learning to express feelings and solve problems in a nonaggressive manner is an example of assertiveness training, rather than free association.

D. CORRECT: Free association is the spontaneous, uncensored verbalization of whatever comes to a client’s mind.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

3. A. CORRECT: Priority restructuring is a cognitive reframing technique.

B. CORRECT: Monitoring thoughts is a cognitive reframing technique.

C. Diaphragmatic breathing is a form of behavioral therapy rather than a cognitive reframing technique.

D. CORRECT: Journal keeping is a cognitive reframing technique.

E. Meditation is a form of behavioral therapy rather than a cognitive reframing technique.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

4. A. CORRECT: Aversion therapy pairs a maladaptive behavior with unpleasant stimuli to promote a change in behavior.

B. Flooding is planned exposure to an undesirable stimulus in an attempt to turn off the anxiety response.

C. Biofeedback is a behavioral therapy to control pain, tension, and anxiety.

D. Dialectical behavior therapy is a cognitive-behavioral therapy for clients who have a personality disorder and exhibit self-injurious behavior.

NCLEX® Connection: Psychosocial Integrity, Chemical and Other Dependencies/Substance Use Disorder

5. A. Demonstration followed by client imitation of the behavior is an example of modeling.

B. Teaching a client to say “stop” when anxiety occurs is an example of thought stopping.

C. CORRECT: Systematic desensitization is the planned, progressive exposure to anxiety-provoking stimuli. During this exposure, relaxation techniques suppress the anxiety response.

D. Exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response is an example of flooding.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE ● Behavioral therapy is based on the theory that behavior is learned and has consequences. These therapies teach clients ways to decrease anxiety or avoidant behavior and give clients an opportunity to practice techniques.

● Operant conditioning provides the client with positive rewards for positive behavior.

OUTCOMES/EVALUATION ● The client will attend group meetings. ● The client will attend unit activities. ● The client will appropriately socialize with other clients on the unit.

NURSING INTERVENTIONS ● The nurse will use tokens, or something similar, to reward the client for a positive change in behavior. The client can use these tokens for larger rewards (a walk outside with a staff member).

● The nurse will provide positive feedback and encouragement for a positive change in behavior.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

RN MENTAL HEALTH NURSING CHAPTER 8 GROUP AND FAMILY THERAPY 41

UNIT 2 TRADITIONAL NONPHARMACOLOGICAL THERAPIES

CHAPTER 8 Group and Family Therapy

Therapy is an intensive treatment that involves open therapeutic communication with participants who are willing to take part in therapy. Although individual therapy is an important treatment for mental illness, group and family therapies are also a part of the treatment plan for many clients in a mental health setting.

Leaders guide group and family therapy, and they can employ various leadership styles. Democratic leadership supports group interaction and decision making to solve problems. In group settings, more than one client can be involved. Groups offer each client opportunities for growth and a feeling of belonging. Laissez-faire leadership progresses without any attempt by the leader to control the direction. In autocratic leadership, the leader completely controls the direction and structure of the group without allowing group interaction or decision making to solve problems.

Examples of group therapy include stress management, substance use disorders, medication education, understanding mental illness, and dual diagnosis groups.

Group therapy Group process is the verbal and nonverbal communication that occurs during group sessions, including how the work progresses and how members interact with one another.

Group norm is the way the group behaves during sessions, and, over time, it provides structure for the group. For example, a group norm could be that members raise their hand to be recognized by the leader before they speak. Another norm could be that all members sit in the same places for each session.

Hidden agenda: Some group members (or the leader) might have goals different from the stated group goals that can disrupt group processes. For example, three members might try to embarrass another member whom they dislike.

A subgroup is a small number of people within a larger group who function separately from the group.

Groups can be open (new members join as old members leave) or closed (no new members join after formation of the group).

The dynamics of a group are affected by the group either being open or closed.

A homogeneous group is one in which all members share a certain chosen characteristic (diagnosis or gender). Membership of heterogeneous groups is not based on a shared chosen personal characteristic. An example of a heterogeneous group is all clients on a unit, including a mixture of men and women who have a wide range of diagnoses.

COMPONENTS OF THERAPY SESSIONS ● Use of open and clear communication ● Cohesiveness and guidelines for the therapy session ● Direction toward a particular goal ● Opportunities for development of interpersonal

skills; resolution of personal and family issues; and development of appropriate, satisfying relationships.

● Encouragement of the client to maximize positive interactions, feel empowered to make decisions, and strengthen feelings of self-worth

● Communication regarding respect among all members ● Support, as well as education regarding things (available

community resources for support)

CHAPTER 8

8.1 Focus and goals for individual, family, and group therapies

Individual FOCUS Client needs and problems The therapeutic relationship

GOALS Make more positive individual decisions. Make productive life decisions. Develop a strong sense of self.

Family FOCUS Family needs and problems within family dynamics Improving family functioning

GOALS Learn effective ways for dealing with mental illness within the family. Improve understanding among family members. Maximize positive interaction among family members.

Group FOCUS Helping individuals develop more functional and satisfying relations within a group setting

GOALS Goals vary depending on type of group, but clients generally: Discover that members share some common feelings, experiences, and thoughts. Experience positive behavior changes as a result of group interaction and feedback.

42 CHAPTER 8 GROUP AND FAMILY THERAPY CONTENT MASTERY SERIES

GROUP THERAPY GOALS ● Sharing common feelings and concerns ● Sharing stories and experiences ● Diminishing feelings of isolation ● Creating a community of healing and restoration ● Providing a more cost-effective environment than that

of individual therapy

AGE GROUPS IN GROUP THERAPY Children: In the form of play while talking about a common experience

Adolescent: Especially valuable, as this age group typically has strong peer relationships

Older adult: Helps with socialization and sharing of memories

PHASES OF GROUP DEVELOPMENT

Orientation phase

PRIMARY FOCUS: Define the purpose and goals of the group.

RESPONSIBILITIES ● The group leader sets a tone of respect, trust, and

confidentiality among members. The group leader is active and provides the purpose of the group.

● Members get to know each other and the group leader. ● There is a discussion about termination.

Working phase

PRIMARY FOCUS: Promote problem-solving skills to facilitate behavioral changes. Power and control issues can dominate in this phase.

RESPONSIBILITIES ● The group leader uses therapeutic communication to

encourage group work toward meeting goals. ● Members take informal roles within the group, which

can interfere with, or favor, group progress toward goals. ● Cohesiveness has been established and role of leader is

gradually diminishing.

Termination phase

PRIMARY FOCUS: This marks the end of group sessions.

RESPONSIBILITIES ● Group members discuss termination issues. ● The leader summarizes work of the group and

individual contributions. ● Members of a group can take on any of a

number of roles. ● Feedback regarding the group therapy is elicited.

ROLES Maintenance roles: Members who take on these roles tend to help maintain the purpose and process of the group. For example, the harmonizer attempts to prevent conflict in the group.

Task roles: Members take on various tasks within the group process. An example is the recorder, who takes notes and records what occurs during each session.

Individual roles: These roles tend to prevent teamwork, because individuals take on roles to promote their own agenda. Examples include the dominator, who tries to control other members, and the recognition seeker, who boasts about personal achievements.

GROUP CHARACTERISTICS Can vary depending on the health care setting.

Acute mental health setting: Members can vary on a daily basis, and the focus of the group is on relief. Unit activities will directly impact the group, and the leader must provide a higher level of structure.

Outpatient setting: Members are often consistent, the focus of the group is on growth, external influences are limited, and the leader can allow members an opportunity in determining the group’s direction.

Families and family therapy TYPES OF FAMILIES

Nuclear families: Include children who reside with married parents

Single-parent families: Include children who live with a single adult that can be related or nonrelated to the children

Adoptive families: Include children who live with parents who have adopted them

Blended families: Include children who live with one biological or adoptive parent and an nonrelated stepparent who are married

Cohabitating families: Include children who live with one biological parent and a nonrelated adult who are cohabitating

Extended families: Include children living with one biological or adoptive parent and a related adult who is not their parent (grandparent, aunt, uncle)

Other families: Include children living with related or nonrelated adults who are neither biological nor adoptive parents (grandparents, adult siblings, foster parents)

Family is the first system to which a person is attached and is the most influential system to which an individual will belong.

RN MENTAL HEALTH NURSING CHAPTER 8 GROUP AND FAMILY THERAPY 43

● Families go through various developmental stages. The roles the family members fulfill change throughout the stages. For instance, when adults become parents they care for and model behavior for their children. As children mature, they rely on their parents less. Later on, the parents can have to depend on their children to meet their needs.

● Families can have healthy or dysfunctional characteristics in one or more areas of functioning.

● Healthy family relationships support the well being of each member of the family unit.

AREAS OF FUNCTIONING

Communication

HEALTHY FAMILIES: There are clear, understandable messages between family members, and each member is encouraged to express individual feelings and thoughts.

DYSFUNCTIONAL FAMILIES One or more members use unhealthy patterns, including

● Blaming: Members blame others to shift focus away from their own inadequacies.

● Manipulating: Members use dishonesty to support their own agendas.

● Placating: One member takes responsibility for problems to keep peace at all costs.

● Distracting: A member inserts irrelevant information during attempts at problem solving.

● Generalizing: Members use overall descriptions (“always” and “never”) in describing family encounters.

Management

HEALTHY FAMILIES: Adults of a family agree on important issues (rule making, finances, plans for the future).

DYSFUNCTIONAL FAMILIES: Management can be chaotic, with a child making management decisions at times.

Boundaries

HEALTHY FAMILIES: Boundaries are distinguishable between family roles. Clear boundaries define roles of each member and are understood by all. Each family member is able to function appropriately.

DYSFUNCTIONAL FAMILIES ● Enmeshed boundaries: Thoughts, roles, and feelings

blend so much that individual roles are unclear. ● Rigid boundaries: Rules and roles are completely

inflexible. These families tend to have members that isolate themselves and communication is minimal. Members do not share thoughts or feelings.

Socialization

HEALTHY FAMILIES: All members interact, plan, and adopt healthy ways of coping. Children learn to function as family members, as well as members of society. Members are able to change as the family grows and matures.

DYSFUNCTIONAL FAMILIES: Children do not learn healthy socialization skills within the family and have difficulty adapting to socialization roles of society.

Emotional/supportive

HEALTHY FAMILIES: Emotional needs of family members are met most of the time, and members have concerns about each other. Conflict and anger do not dominate.

DYSFUNCTIONAL FAMILIES: Negative emotions predominate most of time. Members are isolated and afraid and do not show concern for each other.

OTHER CONCEPTS RELATED TO FAMILY DYSFUNCTION

Scapegoating: A member of the family with little power is blamed for problems within the family. For example, one child who has not completed their chores can be blamed for the entire family not being able to go on an outing.

Triangulation: A third party is drawn into the relationship with two members whose relationship is unstable. For example, one parent can develop an alliance with a child, leaving the other parent relatively uninvolved with both.

Multigenerational issues: These are emotional issues or themes within a family that continue for at least three generations (a pattern of substance use or addictive behavior, dysfunctional grief patterns, triangulation patterns, divorce).

DISCIPLINE Family behavior that can be healthy or dysfunctional is the action of disciplining. Setting limits on children’s behavior protects their safety and provides them with security. Disciplining should be consistent, timely, and age appropriate. Parents should administer discipline in private, when they are calm. Caregivers should be in unison on when and how to discipline.

FAMILY THERAPY A family is defined as a group with reciprocal relationships in which members are committed to each other. Examples of a family vary widely and are often nontraditional (a family made up of a child living with a grown brother and his partner). Areas of functioning for families include management, boundaries, communication, emotional support, and socialization. Dysfunction can occur in any one or more areas. ● In family therapy, the focus is on the family as a system,

rather than on each person as an individual. ● Family assessments include focused interviews and use

of various family assessment tools. ● Nurses work with families to provide teaching. For

example, an RN might instruct a family on medication administration, or ways to help a family member manage their mental health disorder.

● Nurses also work to mobilize family resources, to improve communication, and to strengthen the family’s ability to cope with the illness of one member.

44 CHAPTER 8 GROUP AND FAMILY THERAPY CONTENT MASTERY SERIES

Application Exercises

1. A nurse wants to use democratic leadership with a group whose purpose is to learn appropriate conflict resolution techniques. The nurse is correct in implementing this form of group leadership when demonstrating which of the following actions?

A. Observes group techniques without interfering with the group process

B. Discusses a technique and then directs members to practice the technique

C. Asks for group suggestions of techniques and then supports discussion

D. Suggests techniques and asks group members to reflect on their use

2. A nurse is planning group therapy for clients dealing with bereavement. Which of the following activities should the nurse include in the initial phase? (Select all that apply.)

A. Encourage the group to work toward goals.

B. Define the purpose of the group.

C. Discuss termination of the group.

D. Identify informal roles of members within the group.

E. Establish an expectation of confidentiality within the group.

3. A nurse on an acute mental health unit forms a group to focus on self-management of medications. At each of the meetings, two of the members conspire together to exclude the rest of the group. This is an example of which of the following concepts?

A. Triangulation

B. Group process

C. Subgroup

D. Hidden agenda

4. A nurse is conducting a family therapy session. The younger child tells the nurse about plans to make the older sibling look bad, believing this will earn more freedom and privileges. The nurse should identify this dysfunctional behavior as which of the following?

A. Placation

B. Manipulation

C. Blaming

D. Distraction

5. A nurse is working with an established group and identifies various member roles. Which of the following should the nurse identify as an individual role?

A. A member who praises input from other members

B. A member who follows the direction of other members

C. A member who brags about accomplishments

D. A member who evaluates the group’s performance toward a standard

Active Learning Scenario

A nurse is creating a plan of care for a family that is planning to begin therapy to improve the emotional and supportive aspect of the family unit. Use the ATI Active Learning Template: Basic Concept to complete this item.

RELATED CONTENT: Identify the definition of a family.

UNDERLYING PRINCIPLES: Discuss the focus of family therapy.

NURSING INTERVENTIONS ● Identify at least two outcomes for

emotional/supportive functioning. ● Identify at least two interventions to

assist the family during therapy.

RN MENTAL HEALTH NURSING CHAPTER 8 GROUP AND FAMILY THERAPY 45

Application Exercises Key

1. A. Laissez-faire leadership allows the group process to progress without any attempt by the leader to control the direction of the group.

B. Autocratic leadership controls the direction of the group. C. CORRECT: Democratic leadership supports group

interaction and decision making to solve problems. D. Autocratic leadership controls the direction of the group.

NCLEX® Connection: Management of Care, Collaboration with Interdisciplinary Team

2. A. During the working phase, the group works toward goals.

B. CORRECT: During the initial phase, identify the purpose of the group.

C. CORRECT: During the initial phase, discuss termination of the group.

D. During the working phase, identify informal roles that other members in the group often assume.

E. CORRECT: During the initial phase, set the tone of the group, including an expectation of confidentiality.

NCLEX® Connection: Psychosocial Integrity, Grief and Loss

3. A. Triangulation is when a third party is drawn into a relationship with two members whose relationship is unstable.

B. Group process is the verbal and nonverbal communication that occurs within the group during group sessions.

C. CORRECT: A subgroup is a small number of people within a larger group who function separately from that group.

D. A hidden agenda is when some group members have a different goal than the stated group goals. The hidden agenda is often disruptive to the effective functioning of the group.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

4. A. Placation is the dysfunctional behavior of taking responsibility for problems to keep peace among family members.

B. CORRECT: Manipulation is the dysfunctional behavior of using dishonesty to support an individual agenda.

C. Blaming is the dysfunctional behavior of blaming others to shift focus away from the individual’s own inadequacies.

D. Distraction is the dysfunctional behavior of inserting irrelevant information during attempts at problem solving.

NCLEX® Connection: Psychosocial Integrity, Family Dynamics

5. A. An individual who praises the input of others is acting in a maintenance role.

B. An individual who is a follower is acting in a maintenance role.

C. CORRECT: An individual who brags about accomplishments is acting in an individual role that does not promote the progression of the group toward meeting goals.

D. An individual who evaluates the group’s performance is acting in a task role.

NCLEX® Connection: Psychosocial Integrity, Behavioral Intervention

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

RELATED CONTENT: A family is defined as a group with reciprocal relationships in which members are committed to each other.

UNDERLYING PRINCIPLES ● Family needs and problems within family dynamics ● Improve family functioning

NURSING INTERVENTIONS ● Outcomes

◯ Family members will have emotional needs met the majority of the time.

◯ Family members will show concern for each other. ◯ Family members will maintain a positive emotional atmosphere rather than one of conflict and anger.

● Interventions ◯ Teach the family effective ways to deal with emotional needs of family members.

◯ Assist the family to improve understanding among family members. ◯ Promote positive interaction among family members. ◯ Identify common feelings, experiences, and thoughts among family members.

NCLEX® Connection: Psychosocial Integrity, Family Dynamics

46 CHAPTER 8 GROUP AND FAMILY THERAPY CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 9 STRESS MANAGEMENT 47

UNIT 2 TRADITIONAL NONPHARMACOLOGICAL THERAPIES

CHAPTER 9 Stress Management Stress is the body’s nonspecific response to any demand made upon it. Stress is the brain’s natural response to any demand. Stressors are physical or psychological factors that produce stress. Any stressor, whether it is perceived as

“good” or “bad,” produces a biological response in the body. Individuals need the presence of some stressors to provide interest and purpose to life; however, too much stress or too many stressors can cause distress. Anxiety and anger are damaging stressors that cause distress.

The body responds to a perceived or actual threat by activating the fight or flight response. If stress is prolonged, maladaptive responses can occur.

Stress management is a client’s ability to experience appropriate emotions and cope with stress. The client who manages stress in a healthy manner is flexible and uses a variety of coping techniques or mechanisms. Responses to stress and anxiety are affected by factors (age, gender, culture, life experiences, and lifestyle). The effects of stressors are cumulative. For example, the death of a family member can cause a high amount of stress. If the client experiencing that stress is also experiencing other stressful events at the same time, this could cause illness due to the cumulative effect of those stressors. A client’s ability to use successful stress management techniques can improve stress-related medical conditions and improve functioning.

ASSESSMENT Protective factors increasing a client’s resilience, or ability to resist the effects of stress, include the following. ● Physical health ● Strong sense of self ● Religious or spiritual beliefs ● Optimism ● Hobbies and other outside interests ● Satisfying interpersonal relationships ● Strong social support systems ● Humor

EXPECTED FINDINGS ACUTE STRESS (FIGHT OR FLIGHT) ● Apprehension ● Unhappiness or sorrow ● Decreased appetite ● Increased respiratory rate, heart rate, cardiac output,

blood pressure ● Increased metabolism and glucose use ● Depressed immune system

PROLONGED STRESS (MALADAPTIVE RESPONSE) ● Chronic anxiety or panic attacks ● Depression, chronic pain, sleep disturbances ● Weight gain or loss ● Increased risk for myocardial infarction, stroke ● Poor diabetes control, hypertension, fatigue, irritability,

decreased ability to concentrate ● Increased risk for infection

STANDARDIZED SCREENING TOOLS Life-changing events questionnaires (the Holmes and Rahe stress scale) to measure Life Change Units, Perceived Stress Scale, and Lazarus’s Cognitive Appraisal.

PATIENT-CENTERED CARE

NURSING CARE Most nursing care involves teaching stress-reduction strategies to clients.

Cognitive techniques

Cognitive reframing ● The client is helped to look at irrational cognitions

(thoughts) in a more realistic light and to restructure those thoughts in a more positive way.

● As an example, a client can think they are “a terrible father to my daughter.” A health professional, using therapeutic communication techniques, could help the client reframe that thought into a positive thought (“I’ve made some bad mistakes as a parent, but I’ve learned from them and have improved my parenting skills.”).

CHAPTER 9

48 CHAPTER 9 STRESS MANAGEMENT CONTENT MASTERY SERIES

Behavioral techniques

RELAXATION TECHNIQUES ● Meditation includes formal meditation techniques, as

well as prayer for those who believe in a higher power. ● Guided imagery: The client is guided through a series

of images to promote relaxation. Images vary depending on the individual. For example, one client might imagine walking on a beach, while another client might imagine themselves in a position of success.

● Breathing exercises are used to decrease rapid breathing and promote relaxation.

● Progressive muscle relaxation: A person trained in this method can help a client attain complete relaxation within a few minutes.

● Physical exercise (yoga, walking, biking) causes release of endorphins that lower anxiety, promote relaxation, and have antidepressant effects.

● Use nursing judgment to determine the appropriateness of relaxation techniques for clients who are experiencing acute manifestations of a psychotic disorder.

Journal writing ● Journaling has been shown to allow for a therapeutic

release of stress. Journaling can ease anxiety, worry, and obsessional thinking. It also can increase confidence and hope.

● This activity can help the client identify stressors and make specific plans to decrease stressors.

Priority restructuring ● The client learns to prioritize differently to reduce the

number of stressors affecting them. ● For example, a person who is under stress due to feeling

overworked might delegate some tasks to others rather than doing them all on their own.

Biofeedback

A nurse or other health professional trained in this method uses a sensitive mechanical device to assist the client to gain voluntary control of such autonomic functions as heart rate and blood pressure. Exercise gadgets and smart watches provide the ability to track sleep and heart rates.

Mindfulness ● The client is encouraged to be mindful of their

surroundings using all of their senses (the relaxing warmth of sunlight or the sound of a breeze blowing through the trees).

● The client learns to restructure negative thoughts and interpretations into positive ones. For example, instead of saying, “It’s so frustrating that the elevator isn’t working,” the client restructures the thought into,

“Using the stairs is a great opportunity to burn off some extra calories.”

Assertiveness training ● The client learns to communicate in a more assertive

manner in order to decrease psychological stressors. ● For example, one technique teaches the client to assert

their feelings by describing a situation or behavior that causes stress, discussing feelings about the behavior or situation, and then making a change. The client states, “When you keep telling me what to do, I feel angry and frustrated. I need to try making some of my own decisions.”

Other individual stress-reduction techniques ● The nurse should assist each client in identifying

individual strategies that improve the client’s ability to cope with stress.

● Examples include individual hobbies (fishing, scrapbooking), music therapy, pet therapy, sleep, massage, and aerobic exercise.

RN MENTAL HEALTH NURSING CHAPTER 9 STRESS MANAGEMENT 49

Active Learning Scenario

A nurse is leading a peer group discussion about teaching stress-related strategies. Use the ATI Active Learning Template: Basic Concept to complete this item.

NURSING INTERVENTIONS: List 3 behavioral and relaxation techniques the nurse should recommend and how to explain their use to the client.

Application Exercises

1. A nurse is preparing an educational seminar on stress for other nursing staff. Which of the following information should the nurse include in the discussion?

A. Excessive stressors cause the client to experience distress.

B. The body’s initial adaptive response to stress is denial. C. Absence of stressors results in homeostasis. D. Negative, rather than positive, stressors

produce a biological response.

2. A nurse is discussing acute vs. prolonged stress with a client. Which of the following effects should the nurse identify as an acute stress response? (Select all that apply.)

A. Chronic pain B. Depressed immune system C. Increased blood pressure D. Panic attacks E. Unhappiness

3. A nurse is teaching a client about stress-reduction techniques. Which of the following client statements indicates understanding of the teaching?

A. “Cognitive reframing will help me change my irrational thoughts to something positive.”

B. “Progressive muscle relaxation uses a mechanical device to help me gain control over my pulse rate.”

C. “Biofeedback causes my body to release endorphins so that I feel less stress and anxiety.”

D. “Mindfulness allows me to prioritize the stressors that I have in my life so that I have less anxiety.”

4. A nurse is talking with a client who reports experiencing increased stress because a new partner is “pressuring me and my kids to go live with him. I love him, but I’m not ready to do that.” Which of the following recommendations should the nurse make to promote a change in the client’s situation?

A. Learn to practice mindfulness. B. Use assertiveness techniques. C. Exercise regularly. D. Rely on the support of a close friend.

5. A nurse is caring for a client who states, “I’m so stressed at work because of my coworker. I am expected to finish others’ work because of their laziness!” When discussing effective communication, which of the following statements by the client to the coworker indicates client understanding?

A. “You really should complete your own work. I don’t think it’s right to expect me to complete your responsibilities.”

B. “Why do you expect me to finish your work? You must realize that I have my own responsibilities.”

C. “It is not fair to expect me to complete your work. If you continue, then I will report your behavior to our supervisor.”

D. “When I have to pick up extra work, I feel very overwhelmed. I need to focus on my own responsibilities.”

50 CHAPTER 9 STRESS MANAGEMENT CONTENT MASTERY SERIES

Application Exercises Key

1. A. CORRECT: Distress is the result of excessive or damaging stressors (anxiety or anger).

B. Denial is part of the grief process. The body’s initial adaptive response to stress is known as the fight-or-flight mechanism.

C. Individuals need the presence of some stressors to provide interest and purpose to life.

D. Both positive and negative stressors produce a biological response in the body.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

2. A. Chronic pain indicates a prolonged or maladaptive stress response.

B. CORRECT: A depressed immune system is an indicator of acute stress.

C. CORRECT: Increased blood pressure is an indicator of acute stress.

D. Panic attacks indicate a prolonged or maladaptive stress response.

E. CORRECT: Unhappiness is an indicator of acute stress.

NCLEX® Connection: Psychosocial Integrity, Stress Management

3. A. CORRECT: Cognitive reframing helps the client look at irrational cognitions (thoughts) in a more realistic light and to restructure those thoughts in a more positive way.

B. Biofeedback, rather than progressive muscle training, uses a mechanical device to promote voluntary control over autonomic functions.

C. Physical exercise, rather than biofeedback, causes a release of endorphins that lower anxiety and reduce stress.

D. Priority restructuring, rather than mindfulness, teaches the client to prioritize differently to reduce the number of stressors.

NCLEX® Connection: Psychosocial Integrity, Stress Management

4. A. Mindfulness is appropriate to decrease the client’s stress. However, it does not promote a change in the client’s situation.

B. CORRECT: Assertive communication allows the client to assert their feelings and then make a change in the situation.

C. Regular exercise is appropriate to decrease the client’s stress. However, it does not promote a change in the client’s situation.

D. Social support is appropriate to decrease the client’s stress. However, it does not promote a change in the client’s situation.

NCLEX® Connection: Psychosocial Integrity, Stress Management

5. A. This statement is an example of disapproving/ disagreeing, which can prompt a defensive reaction and is therefore nontherapeutic.

B. This statement uses a “why” question, which implies criticism and can prompt a defensive reaction and is therefore nontherapeutic.

C. This statement is aggressive and threatening, which can prompt a defensive reaction and is therefore nontherapeutic.

D. CORRECT: This response demonstrates assertive communication, which allows the client to state his feelings about the behavior and then promote a change.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

Active Learning Scenario Key

Using the ATI Active Learning Template: Basic Concept

NURSING INTERVENTIONS ● Meditation includes formal meditation techniques, as well as prayer for those who believe in a higher power.

● Guided imagery: The client is guided through a series of images to promote relaxation. Images vary depending on the individual. For example, one client might imagine walking on a beach, while another client might imagine themselves in a position of success.

● Breathing exercises: These are used to decrease rapid breathing and promote relaxation.

● Progressive muscle relaxation: A person trained in this method can help a client attain complete relaxation within a few minutes.

● Physical exercise (yoga, walking, biking): This causes the release of endorphins that lower anxiety, promote relaxation, and have antidepressant effects.

Use nursing judgment to determine the appropriateness of relaxation techniques for clients who are experiencing acute manifestations of a psychotic disorder.

NCLEX® Connection: Psychosocial Integrity, Stress Management

RN MENTAL HEALTH NURSING CHAPTER 10 BRAIN STIMULATION THERAPIES 51

UNIT 2 TRADITIONAL NONPHARMACOLOGICAL THERAPIES

CHAPTER 10 Brain Stimulation Therapies

Brain stimulation therapies offer a nonpharmacological treatment for clients who have certain mental health disorders. Brain stimulation therapies include electroconvulsive therapy (ECT), transcranial magnetic stimulation (TMS), and vagus nerve stimulation (VNS).

Electroconvulsive therapy ECT uses electrical current to induce brief seizure activity while the client is anesthetized. The exact mechanism of ECT is still unknown. One theory suggests that the seizure activity produced by ECT can enhance the effects of neurotransmitters (serotonin, dopamine, and norepinephrine) in the brain.

INDICATIONS

POTENTIAL DIAGNOSES

Major depressive disorder ● Clients whose manifestations are not responsive to

pharmacological treatment ● Clients for whom the risks of other treatments outweigh

the risks of ECT ● Clients who are suicidal or homicidal and for whom

there is a need for rapid therapeutic response ● Clients who are experiencing psychotic manifestations

Schizophrenia spectrum disorders ● Clients who have schizophrenia with catatonic

manifestations ● Clients who have schizoaffective disorder

Acute manic episodes ● Clients who have bipolar disorder with rapid cycling

(four or more episodes of acute mania within 1 year) ● Clients who are unresponsive to treatment with lithium

and antipsychotic medications

CONTRAINDICATIONS There are no absolute contraindications. However, the nurse should assess for medical conditions that place clients at higher risk of adverse effects. These conditions include the following. ● Cardiovascular disorders: Recent myocardial infarction,

hypertension, heart failure, cardiac arrhythmias. ECT increases the stress on the heart due to seizure activity that occurs during the treatment.

● Cerebrovascular disorders: History of stroke, brain tumor, subdural hematoma. ECT increases intracranial pressure and blood flow through the brain during treatment.

Mental health conditions for which ECT has not been found useful include the following.

● Substance use disorders ● Personality disorders ● Dysphoric disorder

CONSIDERATIONS

PROCEDURAL CARE ● The typical course of ECT treatment is two to

three times a week for a total of 6 to 12 treatments for depression.

● The provider obtains informed consent. If ECT is involuntary, the provider can obtain consent from next of kin or a court order.

● Pre-ECT work up can include a chest x-ray, blood work, ECG. Benzodiazepines should be discontinued as they will interfere with the seizure process.

● MEDICATION MANAGEMENT ◯ Thirty minutes prior to the beginning of the

procedure, an IM injection of atropine sulfate or glycopyrrolate is administered to decrease secretions that could cause aspiration and to counteract any vagal stimulation effects (bradycardia).

◯ At the time of the procedure, an anesthesia provider administers a short-acting anesthetic (etomidate or propofol) via IV bolus.

◯ A muscle relaxant (succinylcholine) is then administered to paralyze the client’s muscles during the seizure activity, which decreases the risk for injury. Succinylcholine paralyzes the respiratory muscles so the client requires assistance with breathing and oxygenation.

● Severe hypertension should be controlled because a short period of hypertension occurs immediately after the ECT procedure.

● Any cardiac conditions (dysrhythmias or hypertension) should be monitored and treated before the procedure.

● The nurse monitors vital signs and mental status before and after the ECT procedure.

CHAPTER 10

52 CHAPTER 10 BRAIN STIMULATION THERAPIES CONTENT MASTERY SERIES

● The nurse assesses the client’s and family’s understanding and knowledge of the procedure and provides teaching as necessary. Many clients and family have misconceptions about ECT due to media portrayals of the procedure. Due to the use of anesthesia and muscle relaxants, the tonic-clonic seizure activity associated with the procedure in the past is no longer an effect of the treatment.

● An IV line is inserted and maintained until full recovery. ● Electrodes are applied to the scalp for

electroencephalogram (EEG) monitoring. ● The client receives 100% oxygen during and after ECT

until the return of spontaneous respirations. ● Ongoing cardiac monitoring is provided, including blood

pressure, electrocardiogram (ECG), and oxygen saturation. ● Clients are expected to become alert about 15 min

following ECT.

COMPLICATIONS

Memory loss and confusion

Short-term memory loss, confusion, and disorientation occurs immediately following the procedure can persist for several hours. Clients have retrograde amnesia which is the loss of memory of events leading up to the procedure and have no memory of the procedure. Memory loss can persist for several weeks. Whether ECT causes permanent memory loss is controversial, but most clients fully recover from any memory deficits.

NURSING ACTIONS ● Provide frequent orientation. ● Provide a safe environment to prevent injury. ● Assist the client with personal hygiene as needed.

Reactions to anesthesia

NURSING ACTIONS: Provide continuous monitoring during the procedure and in the immediate recovery phase.

Cardiovascular changes

NURSING ACTIONS: Monitor vital signs and cardiac rhythm regularly per protocol.

Relapse of depression

CLIENT EDUCATION: ECT is not a permanent cure. Weekly or monthly maintenance ECT can decrease the incidence of relapse.

Transcranial magnetic stimulation

TMS is a noninvasive therapy that uses magnetic pulsations (MRI strength) to stimulate the cerebral cortex of the brain.

INDICATIONS TMS is approved by the United States Food and Drug Administration (FDA) for the treatment of major depressive disorder for clients who are not responsive to pharmacological treatment. TMS is similar to ECT but does not induce seizure activity.

CONSIDERATIONS Educate the client about TMS. ● TMS is commonly prescribed daily for a period of 4

to 6 weeks. ● TMS can be performed as an outpatient procedure. ● The TMS procedure lasts 30 to 40 min. ● A noninvasive electromagnet is placed on the client’s

scalp, allowing the magnetic pulsations to pass through. ● The client is alert during the procedure. ● Clients might feel a tapping or knocking sensation in

the head, scalp skin contraction, and tightening of the jaw muscles during the procedure.

COMPLICATIONS ● Common adverse effects include mild discomfort or

a tingling sensation at the site of the electromagnet and headaches.

● Monitor for lightheadedness after the procedure. ● Seizures are a rare but potential complication. ● TMS is not associated with systemic adverse effects or

neurologic deficits. TMS is contraindicated for clients who have cochlear implants, brain stimulators, or medication pumps because the metal in the devices can interfere with the treatment.

RN MENTAL HEALTH NURSING CHAPTER 10 BRAIN STIMULATION THERAPIES 53

Vagus nerve stimulation ● VNS provides electrical stimulation through the vagus

nerve to the brain through a device that is surgically implanted under the skin on the client’s chest similar to a pacemaker device.

● VNS is believed to result in an increased level of neurotransmitters and enhances the actions of antidepressant medications.

INDICATIONS ● Depression that is resistant to pharmacological treatment

and/or ECT. The treatment is approved by the FDA. ● Current research studies are determining the

effectiveness for VNS in clients who have anxiety disorders, obesity, and pain.

CONSIDERATIONS ● Educate the client about VNS.

◯ VNS is commonly performed as an outpatient surgical procedure.

◯ The VNS device delivers around-the-clock programmed pulsations, usually every 5 minutes for a duration of 30 seconds.

◯ Therapeutic antidepressant effects usually take several weeks to achieve.

◯ The client can turn off the VNS device at any time by placing a special external magnet over the site of the implant.

● Assist the provider in obtaining informed consent.

COMPLICATIONS ● Voice changes due to the proximity of the implanted

lead on the vagus nerve to the larynx and pharynx. ● Other potential adverse effects include hoarseness,

throat or neck pain, coughing. These commonly improve with time.

● Dyspnea, especially with physical exertion, is possible. Therefore, the client might want to turn off the VNS during exercise or when periods of prolonged speaking are required.

Active Learning Scenario

A nurse is preparing to assist in providing electroconvulsive therapy (ECT) treatment for a client. Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.

DESCRIPTION OF PROCEDURE

NURSING INTERVENTIONS (PRE, INTRA, POST) ● Identify two preprocedure medication management actions. ● Identify at least two intraprocedure actions.

Application Exercises

1. A nurse is providing teaching for a client who is scheduled to receive ECT for the treatment of major depressive disorder. Which of the following client statements indicates understanding of the teaching?

A. “It is common to treat depression with ECT before trying medications.”

B. “I can have my depression cured if I receive a series of ECT treatments.”

C. “I should receive ECT once a week for 6 weeks.”

D. “I will receive a muscle relaxant to protect me from injury during ECT.”

2. A charge nurse is discussing TMS with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. “TMS is indicated for clients who have schizophrenia spectrum disorders.”

B. “I will provide postanesthesia care following TMS.”

C. “TMS treatments usually last 5 to 10 minutes.”

D. “I will schedule the client for TMS treatments 3 to 5 times a week for the first several weeks.”

3. A nurse is assessing a client immediately following an ECT procedure. Which of the following findings should the nurse expect? (Select all that apply.)

A. Hypotension

B. Paralytic ileus

C. Memory loss

D. Polyuria

E. Confusion

4. A nurse is leading a peer group discussion about the indications for ECT. Which of the following indications should the nurse include in the discussion?

A. Borderline personality disorder

B. Acute withdrawal related to a substance use disorder

C. Bipolar disorder with rapid cycling

D. Dysphoric disorder

5. A nurse is planning care for a client following surgical implantation of a VNS device. The nurse should plan to monitor for which of the following adverse effects? (Select all that apply.)

A. Voice changes

B. Seizure activity

C. Disorientation

D. Cough

E. Neck pain

54 CHAPTER 10 BRAIN STIMULATION THERAPIES CONTENT MASTERY SERIES

Application Exercises Key

1. A. ECT is indicated for clients who have major depressive disorder and who are not responsive to pharmacological treatment.

B. ECT does not cure depression. However, it can reduce the incidence and severity of relapse.

C. The typical course of ECT treatment is two to three times a week for a total of six to 12 treatments.

D. CORRECT: A muscle relaxant (succinylcholine) is administered to reduce the risk for injury during induced seizure activity.

NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures

2. A. TMS is indicated for the treatment of major depressive disorder that is not responsive to pharmacological treatment. ECT is indicated for the treatment of schizophrenia spectrum disorders.

B. Postanesthesia care is not necessary after TMS because the client does not receive anesthesia and is alert during the procedure.

C. The TMS procedure lasts 30 to 40 min. D. CORRECT: TMS is commonly prescribed 3 to

5 times a week for the first four to six weeks.

NCLEX® Connection: Physiological Adaptation, Illness Management

3. A. Immediately following ECT, the client’s blood pressure is expected to be elevated.

B. Paralytic ileus is not an expected finding of ECT. C. CORRECT: Transient short-term memory loss is an

expected finding immediately following ECT. D. Polyuria is not an expect finding of ECT. E. CORRECT: Confusion is an expected finding

immediately following ECT.

NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures

4. A. ECT has not been found to be effective for the treatment of personality disorders.

B. ECT has not been found to be effective for the treatment of substance use disorders.

C. CORRECT: ECT is indicated for the treatment of bipolar disorder with rapid cycling.

D. ECT has not been found effective for the treatment of dysphoric disorder.

NCLEX® Connection: Physiological Adaptation, Illness Management

5. A. CORRECT: Voice changes are a common adverse effect of VNS due to the proximity of the implanted lead on the vagus nerve to the larynx and pharynx.

B. Seizure activity is associated with ECT rather than VNS. C. Disorientation is associated with ECT rather than VNS. D. CORRECT: Coughing is a potential adverse effect of VNS. E. CORRECT: Neck pain is a potential adverse effect of

VNS. However, this usually subsides with time.

NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE: ECT is a nonpharmacologic brain stimulation therapy for the treatment of mental health disorders, especially major depressive disorder. ECT induces seizure activity, which is thought to enhance the effects of neurotransmitters in the brain.

NURSING ACTIONS (PRE, INTRA, POST) ● Preprocedure medication management actions

◯ Administer atropine sulfate or glycopyrrolate 30 min prior to ECT. ◯ Establish IV access prior to ECT. ◯ Inform the client that the anesthesia provider will administer a

short-acting anesthetic (etomidate or propofol) via IV bolus. ◯ Inform the client that a muscle relaxant (succinylcholine) is

administered to paralyze the client’s muscles during the seizure activity, which decreases the risk for injury.

● Intraprocedure actions ◯ Apply electrodes to the scalp for EEG monitoring. ◯ Apply cardiac electrodes for ECG monitoring. ◯ Assist with the administration of 100% oxygen during and

after ECT until the return of spontaneous respirations. ◯ Monitor vital signs.

NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures

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RN MENTAL HEALTH NURSING NCLEX® CONNECTIONS 55

NCLEX® Connections

When reviewing the following chapters, keep in mind the relevant topics and tasks of the NCLEX outline, in particular:

Safety and Infection Control ACCIDENT/ERROR/INJURY PREVENTION Identify deficits that may impede client safety.

Implement seizure precautions for at-risk clients.

Protect client from injury.

Health Promotion and Maintenance HEALTH PROMOTION/DISEASE PREVENTION: Identify risk factors for disease/illness.

Psychosocial Integrity BEHAVIORAL INTERVENTIONS Assist client with achieving and maintaining self-control of behavior.

Incorporate behavioral management techniques when caring for a client.

CRISIS INTERVENTION Use crisis intervention techniques to assist the client in coping.

Apply knowledge of client psychopathology to crisis intervention.

MENTAL HEALTH CONCEPTS Recognize signs and symptoms of acute and chronic mental illness.

Assess client for alterations in mood, judgment, cognition and reasoning.

Provide care and education for acute and chronic psychosocial health issues.

SENSORY/PERCEPTUAL ALTERATIONS: Provide care for a client experiencing visual, auditory or cognitive distortions.

SUBSTANCE USE AND OTHER DISORDERS AND DEPENDENCIES Assess client for substance abuse, dependency, withdrawal, or toxicities and intervene as appropriate

Educate client on substance use diagnosis and treatment plan

THERAPEUTIC ENVIRONMENT: Promote a therapeutic environment.

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56 NCLEX® CONNECTIONS CONTENT MASTERY SERIES

Reduction of Risk Potential POTENTIAL FOR ALTERATIONS IN BODY SYSTEMS: Compare client data to baseline client data.

Pharmacological and Parenteral Therapies EXPECTED ACTIONS/OUTCOMES: Evaluate client response to medication.

RN MENTAL HEALTH NURSING CHAPTER 11 ANXIETY DISORDERS 57

UNIT 3 PSYCHOBIOLOGIC DISORDERS

CHAPTER 11 Anxiety Disorders Normal anxiety is a healthy response to stress that is essential for survival. When anxiety is elevated or persistent, behavior changes and impairment of function can occur. These changes, known as anxiety disorders, tend to be persistent and often disabling.

Anxiety levels can be mild (restlessness, increased motivation, irritability), moderate (agitation, muscle tightness), severe (inability to function, ritualistic behavior, unresponsive), or panic (distorted perception, loss of rational thought, immobility).

TYPES OF DISORDERS

ANXIETY DISORDERS Anxiety disorders recognized and defined by the DSM-5 include the following:

Separation anxiety disorder: The client experiences excessive fear or anxiety when separated from an individual to which the client is emotionally attached.

Specific�phobias: The client experiences an irrational fear of a certain object or situation. Specific clinical names are used to refer to specific phobias (monophobia = phobia of being alone; zoophobia = phobia of animals; acrophobia = phobia of heights).

Agoraphobia: The client experiences an extreme fear of certain places (the outdoors or being on a bridge) where the client feels vulnerable or unsafe.

Social anxiety disorder (social phobia): The client experiences excessive fear of social or performance situations.

Panic disorder: The client experiences recurrent panic attacks.

Generalized�anxiety�disorder�(GAD): The client exhibits uncontrollable, excessive worry for at least 6 months.

OBSESSIVE COMPULSIVE DISORDERS Obsessive-compulsive and related disorders are not actual anxiety disorders but have similar effects and include the following:

Obsessive�compulsive�disorder�(OCD): The client has intrusive thoughts of unrealistic obsessions and tries to control these thoughts with compulsive behaviors, such as repetitive cleaning of a particular object or washing of hands.

Hoarding disorder: The client has difficulty parting with possessions, resulting in extreme stress and functional impairments.

Body dysmorphic disorder: The client has a preoccupation with perceived flaws or defects in physical appearance.

ASSESSMENT

RISK FACTORS ● Most anxiety disorders are more likely to occur in

females. Obsessive-compulsive and related disorders also affect females more than males with the exception of hoarding disorder, which has a higher prevalence rate among males. Anxiety and obsessive-compulsive disorders have a genetic and neurobiological link.

● Clients can experience anxiety due to an acute medical condition, (hyperthyroidism or pulmonary embolism). It is important to assess the manifestations of anxiety in a medical facility to rule out a physical cause.

● Adverse effects of many medications can mimic anxiety disorders.

● Substance-induced anxiety is related to current use of a chemical substance or to withdrawal effects from a substance (alcohol).

EXPECTED FINDINGS

Separation anxiety disorder ● The client exhibits excessive levels of anxiety and

concern when separated from someone to whom they have an emotional attachment, fearing that something tragic will occur resulting in permanent separation.

● The client’s anxiety disrupts the ability to participate in routine daily activities.

● Physical manifestations of anxiety develop during the separation or in anticipation of the separation and include headaches, nausea and vomiting, and sleep disturbances.

Specific phobias ● The client reports a fear of specific objects

(spiders, snakes, or strangers). ● The client reports a fear of specific experiences,

(flying, being in the dark, riding in an elevator, or being in an enclosed space).

● The client might experience anxiety manifestations just by thinking of the feared object or situation and might attempt to decrease the anxiety through the use of alcohol or other substances.

Agoraphobia ● The client avoids certain places or situations that cause

anxiety. This avoidance might disrupt the client’s ability to maintain employment or participate in routine activities of daily life.

● The client’s fear and manifestations of anxiety are out of proportion with the actual danger of the place or situation.

CHAPTER 11

58 CHAPTER 11 ANXIETY DISORDERS CONTENT MASTERY SERIES

Social phobia ● The client reports difficulty performing or speaking in

front of others or participating in social situations due to an excessive fear of embarrassment or poor performance.

● The client might report physical manifestations (actual or factitious) in an attempt to avoid the social situation or need to perform.

Panic disorder ● Panic attacks typically last 15 to 30 min. ● Four or more of the following manifestations are present

during a panic attack: ◯ Palpitations ◯ Shortness of breath ◯ Choking or smothering sensation ◯ Chest pain ◯ Nausea ◯ Feelings of depersonalization ◯ Fear of dying or insanity ◯ Chills or hot flashes

● The client might experience behavior changes and/or persistent worries about when the next attack will occur.

Generalized anxiety disorder ● The client exhibits uncontrollable, excessive worry for

the majority of days over at least 6 months. ● GAD causes significant impairment in one or more areas

of functioning (work-related duties). ● Manifestations of GAD include the following:

◯ Restlessness ◯ Muscle tension ◯ Avoidance of stressful activities or events ◯ Increased time and effort required to prepare for

stressful activities or events ◯ Procrastination in decision making ◯ Sleep disturbance

Obsessive-compulsive disorders

OCD: The client attempts to suppress persistent thoughts or urges that cause anxiety through compulsive or obsessive behaviors (repetitive handwashing). Obsessions or compulsions are time-consuming and result in impaired social and occupational functioning.

Hoarding disorder: The client has an obsessive desire to save items regardless of value and experiences extreme stress with thoughts of discarding or getting rid of items. The client’s hoarding behavior results in social and occupational impairment and often leads to an unsafe living environment.

Body dysmorphic disorder: The client attempts to conceal a perceived physical flaw and practices repetitive behaviors (mirror checking or comparison to others) in response to the anxiety experienced over the perception. The client might have social and occupational impairment in response to the perceived physical defects or flaws.

STANDARDIZED SCREENING TOOLS ● Hamilton Rating Scale for Anxiety ● Fear Questionnaire (phobias) ● Panic Disorder Severity Scale ● Yale-Brown Obsessive Compulsive Scale ● Hoarding Scale Self-Report

PATIENT-CENTERED CARE

NURSING CARE ● Provide a structured interview to keep the client focused

on the present. ● Assess for comorbid condition of substance use disorder. ● Provide safety and comfort to the client during the

crisis period of these disorders, as clients in severe- to panic-level anxiety are unable to problem solve and focus. Clients experiencing panic-level anxiety benefit from a calm, quiet environment.

● Remain with the client during the worst of the anxiety to provide reassurance.

● Perform a suicide risk assessment. ● Provide a safe environment for other clients and staff. ● Provide milieu therapy that employs the following:

◯ A structured environment for physical safety and predictability

◯ Monitoring for, and protection from, self-harm or suicide

◯ Daily activities that encourage the client to share and be cooperative

◯ Use of therapeutic communication skills (open-ended questions) to help the client express feelings of anxiety, and to validate and acknowledge those feelings

◯ Client participation in decision making regarding care ● Use relaxation techniques with the client as needed for

relief of pain, muscle tension, and feelings of anxiety. ● Instill hope for positive outcomes (but avoid

false reassurance). ● Enhance client self-esteem by encouraging positive

statements and discussing past achievements. ● Assist the client to identify defense mechanisms that

interfere with recovery. ● Postpone health teaching until after acute anxiety

subsides. Clients experiencing a panic attack or severe anxiety are unable to concentrate or learn.

● Identify counseling, group therapy, and other community resources for clients who have anxiety.

MEDICATIONS SSRI antidepressants , (sertraline or paroxetine), are the first line of treatment for anxiety and obsessive- compulsive disorders.

SNRI antidepressants , (venlafaxine or duloxetine), are effective in the treatment of anxiety disorders.

Antianxiety medications are helpful in treating the manifestations of anxiety disorders. Benzodiazepines (diazepam) are indicated for short-term use. Buspirone is effective in managing anxiety and can be taken for long-term treatment of anxiety.

RN MENTAL HEALTH NURSING CHAPTER 11 ANXIETY DISORDERS 59

Other medications that can be used to treat anxiety disorders include beta blockers and antihistamines to decrease anxiety. Anticonvulsants are used as mood stabilizers for the client who is experiencing anxiety.

THERAPEUTIC PROCEDURES

Cognitive behavioral therapy

The anxiety response can be decreased by changing cognitive distortions. This therapy uses cognitive reframing to help the client identify negative thoughts that produce anxiety, examine the cause, and develop supportive ideas that replace negative self-talk.

Behavioral therapies

Behavioral therapies teach clients ways to decrease anxiety or avoidant behavior and allow an opportunity to practice techniques.

Relaxation training is used to control pain, tension, and anxiety. Refer to the chapter on Stress Management, which covers relaxation training techniques.

Modeling allows a client to see a demonstration of appropriate behavior in a stressful situation. The goal of therapy is that the client will imitate the behavior.

Systematic desensitization begins with mastering of relaxation techniques. Then, a client is exposed to increasing levels of an anxiety-producing stimulus (either imagined or real) and uses relaxation to overcome the resulting anxiety. The goal of therapy is that the client is able to tolerate a greater and greater level of the stimulus until anxiety no longer interferes with functioning. This form of therapy is especially effective for clients who have phobias.

Flooding involves exposing the client to a great deal of an undesirable stimulus in an attempt to turn off the anxiety response. This therapy is useful for clients who have phobias.

Response prevention focuses on preventing the client from performing a compulsive behavior with the intent that anxiety will diminish.

Thought stopping teaches a client to say “stop” when negative thoughts or compulsive behaviors arise, and substitute a positive thought. The goal of therapy is that with time, the client uses the command silently.

CLIENT EDUCATION ● Monitor for manifestations of anxiety. ● Notify the provider of worsening effects and do not

adjust medication dosages. Avoid stopping or increasing medication without consulting the provider.

● Evaluate coping mechanisms that work and do not work for controlling the anxiety, and learn new methods. Use of alternative stress relief and coping mechanisms might increase medication effectiveness and decrease the need for medication in most cases.

Application Exercises

1. A nurse observes a client who has OCD repeatedly applying, removing, and then reapplying makeup. The nurse identifies that repetitive behavior in a client who has OCD is due to which of the following underlying reasons?

A. Narcissistic behavior B. Fear of rejection from staff C. Attempt to reduce anxiety D. Adverse effect of antidepressant medication

2. A nurse is caring for a client who is experiencing a panic attack. Which of the following actions should the nurse take?

A. Discuss new relaxation techniques. B. Show the client how to change the behavior. C. Distract the client with a television show. D. Stay with the client and remain quiet.

3. A nurse is assessing a client who has generalized anxiety disorder. Which of the following findings should the nurse expect? (Select all that apply.)

A. Excessive worry for 6 months B. Impulsive decision making C. Delayed reflexes D. Restlessness E. Sleep disturbance

4. A nurse is planning care for a client who has body dysmorphic disorder. Which of the following actions should the nurse plan to take first?

A. Assess the client’s risk for self-harm B. Instill hope for positive outcomes C. Encourage the client to participate

in group therapy sessions D. Assist the client to participate

in treatment decisions

5. A nurse is caring for a client who has generalized anxiety disorder and is experiencing severe anxiety. Which of the following statements actions should the nurse make?

A. “Tell me about how you are feeling right now.” B. “You should focus on the positive things

in your life to decrease your anxiety.” C. “Why do you believe you are

experiencing this anxiety?” D. “Let’s discuss the medications your provider

is prescribing to decrease your anxiety.”

Active Learning Scenario

A nurse working in a mental health clinic is working with a client who experiences high levels of anxiety when riding in an elevator. What should the nurse teach the client bout the use of systematic desensitization as a form of behavioral therapy. Use the ATI Active Learning Template: Therapeutic Procedure to complete this item.

DESCRIPTION OF PROCEDURE

INDICATIONS: Describe one.

OUTCOMES/EVALUATION: Identify at least two client outcomes.

60 CHAPTER 11 ANXIETY DISORDERS CONTENT MASTERY SERIES

Application Exercises Key

1. A. Narcissism causes clients to seek admiration from others. B. Fear of rejection might cause a client to avoid social situations

and might be associated with social phobia anxiety disorder. C. CORRECT: Clients who have OCD demonstrate

repetitive behavior in an attempt to suppress persistent thoughts or urges that cause anxiety.

D. Clients who have OCD might take an antidepressant to help control repetitive behavior.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

2. A. During a panic attack, the client is unable to concentrate on learning new information.

B. During a panic attack, the client is unable to concentrate on learning new information.

C. During a panic attack, avoid further stimuli that can increase the client’s level of anxiety.

D. CORRECT: During a panic attack, quietly remain with the client. This promotes safety and reassurance without additional stimuli.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

3. A. CORRECT: Generalized anxiety disorder is characterized by uncontrollable, excessive worry for more than 6 months.

B. Generalized anxiety disorder is characterized by procrastination in decision making.

C. Generalized anxiety disorder is characterized by muscle tension.

D. CORRECT: Generalized anxiety disorder is characterized by restlessness.

E. CORRECT: Generalized anxiety disorder is characterized by the presence of sleep disturbances (the inability to fall asleep).

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

4. A. CORRECT: The greatest risk to a client who has an anxiety or obsessive-compulsive disorder is self- harm or suicide. Therefore, the first action to take is to assess the client’s risk for self-harm to ensure that the client is provided with a safe environment.

B. Instill hope for positive outcomes, without providing false reassurance, as part of milieu therapy; however, there is another action to take first.

C. Encourage the client to participate in group therapy to assist the client in order to address social impairments that result from the disorder; however, there is another action to take first.

D. Encourage the client to participate in treatment decisions as part of milieu therapy; however, there is another action to take first.

NCLEX® Connection: Physiological Adaptation, Pathophysiology

5. A. CORRECT: Asking an open-ended question is therapeutic and assists the client in identifying anxiety.

B. Offering advice is nontherapeutic and can hinder further communication.

C. Asking the client a “why” question is nontherapeutic and can promote a defensive client response.

D. Postpone health teaching until after acute anxiety subsides. Clients experiencing severe anxiety are unable to concentrate or learn.

NCLEX® Connection: Psychosocial Integrity, Stress Management

Active Learning Scenario Key

Using the ATI Active Learning Template: Therapeutic Procedure

DESCRIPTION OF PROCEDURE: Systematic desensitization is a behavioral therapy that exposes clients to increasing levels of an anxiety-producing stimulus.

INDICATIONS: Systematic desensitization is indicated for the treatment of anxiety disorders associated with an anxiety-producing stimulus (a specific phobia).

OUTCOMES/EVALUATION ● The client will demonstrate effective relaxation techniques to overcome anxiety.

● The client’s level of functioning will not be impaired by the phobia. ● The client will verbalize decreased feelings of anxiety when encountering the stimulus.

NCLEX® Connection: Psychosocial Integrity, Stress Management

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RN MENTAL HEALTH NURSING CHAPTER 12 TRAUMA- AND STRESSOR-RELATED DISORDERS 61

UNIT 3 PSYCHOBIOLOGIC DISORDERS

CHAPTER 12 Trauma- and Stressor-Related Disorders

Clients can develop a trauma- or stressor-related disorder following exposure to an extreme stressor (military combat or interpersonal violence). It is important that nurses have an understanding of how to effectively assess and care for clients experiencing this type of disorder.

SPECIFIC DISORDERS Acute stress disorder (ASD): Exposure to traumatic events causes anxiety, detachment and other manifestations about the event for at least 3 days but for not more than 1 month following the event.

Posttraumatic�stress�disorder�(PTSD): Exposure to traumatic events causes anxiety, detachment, and other manifestations about the event for longer than 1 month following the event. Manifestations can last for years.

Adjustment disorder: A stressor triggers a reaction causing changes in mood and/or dysfunction in performing usual activities. The stressor and effects are less severe than with ASD or PTSD.

Dissociative disorders ● Depersonalization/derealization disorder: This disorder

is characterized by a temporary change in awareness displaying depersonalization, derealization, or both, often in response to stress. Depersonalization is the feeling that a person is observing one’s own personality or body from a distance. Derealization is the feeling that outside events are unreal or part of a dream, or that objects appear larger or smaller than they should.

● Dissociative amnesia: Inability to recall personal information related to traumatic or stressful events. The amnesia can be of events of a certain period of time or just certain details.

● Dissociative fugue: A type of dissociative amnesia in which the client travels to a new area and is unable to remember one’s own identity and at least some of one’s past. Can last weeks to months and usually follows a traumatic event.

● Dissociative identity disorder: Client displays more than one distinct personality, with a stressful event precipitating the change from one personality to another.

HEALTH PROMOTION AND DISEASE PREVENTION

The nurse should monitor for and recognize child physical and sexual abuse, which can lead to ASD or PTSD, and report suspected cases to the proper authorities promptly to prevent severe trauma reactions from occurring.

The nurse should recognize occupations that have a high incidence of PTSD (military or first responders). Clients should receive support and treatment before severe trauma reactions occur.

PTSD PREVENTION Health promotion measures to prevent PTSD during and after a traumatic incident (a mass casualty incident)

● During the incident, be aware of need for breaks, rest, adequate water, and nutrition.

● Provide emotional support for those involved in the incident.

● Encourage staff to support each other. ● Debrief with others following the incident. ● Encourage expression of feelings by all involved. ● Use offered counseling resources.

ASSESSMENT

RISK FACTORS

ASD, PTSD, and adjustment disorder ● Exposure to a traumatic event or experience (motor

vehicle crash, sexual assault, physical abuse). For adjustment disorder, the event or experience can be less severe (breakup of a relationship or loss of employment).

● Exposure to trauma experienced during a natural disaster (fire, storm), or a man-made experience (terrorism)

● Exposure or repeated re-exposure to trauma in an occupational setting (experienced by medical personnel or law enforcement officers) can precipitate a trauma- and stressor-related disorder.

● Living through a traumatic event experienced by a family member or close friend (an airplane crash or homicide)

● PTSD is a risk factor for other disorders, including dissociative disorders, anxiety, depression, and substance use disorders

ASD and PTSD ● Severity of the trauma (duration of the experience,

the amount of personal threat associated with the trauma and whether it occurs far from home or in familiar surroundings)

● Individual vulnerabilities (past coping mechanisms, personality, and preexisting mental disorders)

● Insufficient treatment following the trauma (client social supports, societal attitudes about the situation, and cultural influences)

CHAPTER 12

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62 CHAPTER 12 TRAUMA- AND STRESSOR-RELATED DISORDERS CONTENT MASTERY SERIES

Adjustment disorder ● Pattern of life-long difficulty accepting change ● Learned pattern of difficulty with social skills or coping

strategies which, when a stressor occurs, can trigger a stress response out of proportion to the stressor

Dissociative disorders ● Traumatic life event ● Childhood abuse or trauma

EXPECTED FINDINGS

ASD and PTSD ● Intrusive findings (presence of memories, flashbacks,

dreams about the traumatic event) ● Memories of the event recur involuntarily and are

distressing to the client ● Flashbacks (dissociative reactions where the client feels

the traumatic event is recurring in the present), such as a military veteran feeling that they are reliving a combat situation after hearing a harmless loud noise

● Night-time dreams related to the traumatic event ● Avoidance of people, places, events, or situations that

bring back reminders of the traumatic event ● Trying to avoid thinking of the event

MOOD AND COGNITIVE ALTERATIONS ● Anxiety or depressive disorders ● Anger, irritability frequently present ● Decreased interest in current activities ● Guilt, negative self-beliefs, and cognitive distortions,

such as, “I am responsible for everything bad that happens.”

● Detachment from others, including friends and family members

● Inability to experience positive emotional experiences, such as love and tenderness

● Dissociative manifestations (amnesia, derealization, depersonalization)

BEHAVIORAL MANIFESTATIONS ● Aggression, irritability, and angry responses

toward others ● Hypervigilance with heightened startle responses ● Inability to focus and concentrate on work or

other activities ● Sleep disturbances, such as insomnia ● Destructive behavior, such as suicidal thoughts or

thoughts of harming others

Adjustment disorder ● Depression ● Anxiety ● Changes in behavior (arguing with others or

driving erratically)

Dissociative disorders

Depersonalization/derealization disorder: Reports of feeling detached from one’s own body or of feeling that one’s personal environment is unreal.

Dissociative amnesia: Lack of memory that can range from name or date of birth to the client’s entire lifetime.

Dissociative identity disorder: Client displays two or more separate personalities. Each personality can be very distinct and different from the other.

DIAGNOSTIC PROCEDURES

ASD, PTSD, and adjustment disorder ● Screening tools (the Primary Care PTSD Screen and the

PTSD Checklist) ● Screening tests for anxiety and depression ● Asking about suicidal ideation ● Mental status examination

Dissociative disorders ● Physical assessment, electroencephalogram, and x-ray

studies to rule out physical trauma (traumatic brain injury, epilepsy)

● Screening to rule out substance use ● Mental status examination and nursing history

NURSING ACTIONS ● Assess recent and remote memory for gaps

or contradictions. ● Check for family and occupational difficulties. ● Ask about occurrence of stressful events. ● Assess for depression, mood shifts, and anxiety. ● Use screening tools (the Dissociative Disorders Interview

Schedule, Somatoform Dissociation Questionnaire and the Dissociative Experience Scale).

PATIENT-CENTERED CARE

NURSING CARE Trauma-informed care involves care management that regards the impact of trauma for the client, and addresses emotional, psychological, and physiological needs.

ASD, PTSD, and adjustment disorder ● Establish a therapeutic relationship, and encourage the

client to share feelings. ● Provide a safe, nonthreatening, routine environment. ● Assess clients for suicidal ideation, and take precautions

as needed. ● Use multiple strategies to decrease anxiety (music

therapy, guided imagery, massage, relaxation therapy, and breathing techniques).

● If the client is a child, involve caregivers in treatment if possible, and use play, art and other age-appropriate strategies to decrease stress.

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RN MENTAL HEALTH NURSING CHAPTER 12 TRAUMA- AND STRESSOR-RELATED DISORDERS 63

Dissociative disorders ● During dissociative periods, help the client make

decisions to lower stress. ● When the client shows readiness, encourage

independence and decision making. ● Use grounding techniques (having the client clap hands

or touch an object). ● Avoid giving the client too much information about past

events to prevent increased stress.

CLIENT EDUCATION ● Practice strategies to reduce anxiety. ● Verbalize negative feelings, and progress at own pace.

MEDICATIONS

ASD and PTSD ● Antidepressants can decrease depression and relieve

anxiety in ASD or PTSD. ◯ Paroxetine and sertraline, selective serotonin reuptake inhibitors

◯ Venlafaxine, a serotonin norepinephrine reuptake inhibitor

◯ Mirtazapine, a norepinephrine and serotonin specific antidepressant

◯ Amitriptyline, a tricyclic antidepressant ● Prazosin, a centrally-acting alpha agonist, can decrease

manifestations of hypervigilance and insomnia. ● Propranolol, a beta-adrenergic blocker, decreases

elevated vital signs and manifestations of anxiety, panic, hypervigilance, and insomnia.

Adjustment disorder and dissociative disorders

Medications might not be prescribed for adjustment disorder or the dissociative disorders unless specific findings of depression or anxiety require treatment.

THERAPEUTIC PROCEDURES Cognitive‑behavioral�therapy�(cognitive�restructuring): The client is helped to change distorted appraisal of events and negative thoughts.

Prolonged exposure therapy: Combines the use of relaxation techniques with exposure to the traumatic situation. The exposure can either be imagined through the use of repeated discussion of the traumatic event or practiced in real-world situations (in vivo) in which the client is exposed to the traumatic situation within safe limits. The repeated exposure eventually results in a decreased anxiety response.

Psychodynamic psychotherapy: Getting in touch with conscious and unconscious thought processes.

Eye�movement�desensitization�and�reprocessing�(EMDR) ● A therapy for both children and adults which uses rapid

eye movements during desensitization techniques in a multi-phase process by a trained therapist.

● Contraindicated for clients who have active suicidal ideation, psychosis, severe dissociative disorders, detached retina or glaucoma, or unstable substance use disorder.

● After developing a treatment plan, teach relaxation techniques to enhance client coping during next stages of EMDR.

Group or family therapy can include support groups or formal therapy.

Crisis intervention immediately following a traumatic incident.

Somatic therapy for dissociative disorders: Psychotherapy works over time to increase awareness of the present and decrease dissociation episodes.

Hypnotherapy can be used for dissociative disorders.

Biofeedback/neurofeedback helps the client learn how to increase awareness and gain control of reactions to a trigger.

INTERPROFESSIONAL CARE ● Refer clients to social workers/case managers for

coordination of community care. ● Collaborate with psychotherapists to ensure

coordination of care.

CLIENT EDUCATION ● Utilize relaxation techniques and other

anxiety-reducing strategies. ● Monitor for causes and manifestations of the disorder. ● Avoid caffeine and alcohol. ● Perform grounding techniques for dissociative disorders.

Observe and experience physical objects (touch a piece of ice, take a shower) or situations and to keep a written journal to identify emotions associated with experiences.

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64 CHAPTER 12 TRAUMA- AND STRESSOR-RELATED DISORDERS CONTENT MASTERY SERIES

Application Exercises

1. A nurse working on an acute mental health unit is caring for a client who has posttraumatic stress disorder (PTSD). Which of the following findings should the nurse expect? (Select all that apply.)

A. Difficulty concentrating on tasks B. Obsessive need to talk about the traumatic event C. Negative self-image D. Recurring nightmares E. Diminished reflexes

2. A nurse is involved in a serious and prolonged mass casualty incident in the emergency department. Which of the following strategies should the nurse use to help prevent developing a trauma-related disorder? (Select all that apply)

A. Avoid thinking about the incident when it is over. B. Take breaks during the incident for food and water. C. Debrief with others following the incident. D. Avoid displays of emotion in the

days following the incident. E. Take advantage of offered counseling.

3. A nurse is collecting an admission history for a client who has acute stress disorder (ASD). Which of the following client behaviors should the nurse expect?

A. The client remembers many details about the traumatic incident.

B. The client expresses heightened elation about what is happening.

C. The client remembers first noticing manifestations of the disorder 6 weeks after the traumatic incident occurred.

D. The client expresses a sense of unreality about the traumatic incident.

4. A nurse is caring for a client who has derealization disorder. Which of the following findings should the nurse identify as an indication of derealization?

A. The client describes a feeling of floating above the ground.

B. The client has suspicions of being targeted in order to be killed and robbed.

C. The client states that the furniture in the room seems to be small and far away.

D. The client cannot recall anything that happened during the past 2 weeks.

5. A nurse in an acute mental health facility is planning care for a client who has dissociative fugue. Which of the following interventions should the nurse add to the plan of care?

A. Teach the client to recognize how stress brings on a personality change in the client.

B. Repeatedly present the client with information about past events.

C. Make decisions for the client regarding routine daily activities.

D. Work with the client on grounding techniques.

Active Learning Scenario

A nurse is caring for a client who has post traumatic stress disorder (PTSD) following several months in a military combat situation. Use the Active Learning Template: System Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS): Differentiate PTSD from acute stress disorder (ASD).

EXPECTED FINDINGS: List three subjective and three objective manifestations of PTSD.

NURSING CARE: List three nursing actions for a client who has PTSD.

THERAPEUTIC PROCEDURES: Describe two therapeutic techniques used to treat a client who has PTSD.

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RN MENTAL HEALTH NURSING CHAPTER 12 TRAUMA- AND STRESSOR-RELATED DISORDERS 65

Application Exercises Key

1. A. CORRECT: Manifestations of PTSD include the inability to concentrate on or complete tasks.

B. A client who has PTSD is reluctant to talk about the traumatic event that triggered the disorder.

C. CORRECT: Manifestations of PTSD include feeling guilty and having a negative self-image.

D. CORRECT: Manifestations of PTSD include recurring nightmares or flashbacks.

E. A client who has PTSD has an increased startle reflex and hypervigilance.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

2. A. Thinking and talking about a traumatic incident can help prevent development of a trauma-related disorder.

B. CORRECT: Taking breaks and remembering to drink water and eat nutritious foods while working during a traumatic incident can help prevent development of a trauma-related disorder.

C. CORRECT: Debriefing with others following a traumatic incident can help prevent development of a trauma-related disorder.

D. Displaying emotions following a traumatic incident can help prevent development of a trauma-related disorder.

E. CORRECT: Taking advantage of counseling offered by an employer or others can help prevent development of a trauma-related disorder.

NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

3. A. The client who has ASD tends to be unable to remember details about the incident and can block the entire incident from memory.

B. The client who has ASD reacts to what is happening with negative emotions (anger, guilt, depression, and anxiety). Elation is an emotion that can occur in clients who have mania.

C. Manifestations of ASD occur immediately to a few days following the event.

D. CORRECT: The client who has ASD often expresses dissociative manifestations regarding the event, which includes a sense of unreality.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

4. A. Feeling that one’s body is floating above the ground is an example of depersonalization, in which the person seems to observe their own body from a distance.

B. Having the idea of being targeted in order to be killed and robbed is an example of a paranoid delusion.

C. CORRECT: Stating that one’s surroundings are far away or unreal in some way is an example of derealization.

D. Being unable to recall any events from the past 2 weeks is an example of amnesia.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

5. A. The client who has dissociative identity disorder displays multiple personalities, while the client who has dissociative fugue has amnesia regarding their identity and past.

B. Avoid flooding the client with information about past events, which can increase the client’s level of anxiety.

C. Encourage the client to make decisions regarding routine daily activities in order to promote improved self-esteem and decrease the client’s feelings of powerlessness.

D. CORRECT: Grounding techniques (stomping the feet, clapping the hands, or touching physical objects) are useful for clients who have a dissociative disorder and are experiencing manifestations of derealization.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS) ● Both disorders follow a traumatic incident or multiple experiences that the client perceives as traumatic.

● ASD manifestations occur soon after the incident but subside within 1 month of the trauma.

● PTSD findings can be delayed for weeks or months after the trauma has subsided and continue for months or years, often causing severe social and occupational implications.

EXPECTED FINDINGS ● Subjective manifestations: Client describes dreams and/ or flashbacks of the traumatic event; client reports having insomnia; client verbalizes guilt and self-blame.

● Objective manifestations: Hyperactive startle reflexes; manifestations of anxiety (tachycardia, hyperventilation); inability to focus in order to complete a simple task.

NURSING CARE ● Monitor for suicidal ideation, and take precautions if it occurs. ● Provide a safe, routine environment for the client. ● Teach strategies to decrease anxiety (breathing techniques or music therapy).

● Encourage the client to share feelings. ● Use therapeutic communication techniques to assist a client who has cognitive distortions.

THERAPEUTIC PROCEDURES: Therapeutic techniques for a client who has PTSD include eye movement desensitization and reprocessing (EMDR), group and family therapy, and cognitive behavioral therapy.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

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66 CHAPTER 12 TRAUMA- AND STRESSOR-RELATED DISORDERS CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 13 DEPRESSIVE DISORDERS 67

UNIT 3 PSYCHOBIOLOGIC DISORDERS

CHAPTER 13 Depressive Disorders

Depression is a mood (affective) disorder that is a widespread issue, ranking high among causes of disability.

A client who has depression has a potential risk for suicide, especially if they have a family or personal history of suicide attempts, comorbid anxiety disorder or panic attacks, comorbid substance use disorder or psychosis, poor self-esteem, a lack of social support, or a chronic medical condition.

COMMON COMORBIDITIES Anxiety disorders: These disorders are comorbid in approximately 70% of clients who have a depressive disorder. This combination makes a client’s prognosis poorer, with a higher risk for suicide and disability.

Psychotic disorders (schizophrenia)

Substance use disorders: Clients often use substances in an attempt to relieve manifestations of depression or self-treat mental health disorders.

Eating disorders

Personality disorders

DEPRESSIVE DISORDERS RECOGNIZED BY THE DSM-5 Major�depressive�disorder�(MDD): A single episode or recurrent episodes of unipolar depression (not associated with mood swings from major depression to mania) resulting in a significant change in a client’s normal functioning (social, occupational, self-care) accompanied by at least five of the following specific clinical findings, which must occur almost every day for a minimum of 2 weeks, and last most of the day. ● Depressed mood ● Difficulty sleeping or excessive sleeping ● Indecisiveness ● Decreased ability to concentrate ● Suicidal ideation ● Increase or decrease in motor activity ● Inability to feel pleasure ● Increase or decrease in weight of more than 5% of total

body weight over 1 month

A bereavement exclusion was previously used when a client experienced clinical findings of depression within the first 2 months after a significant loss. Now, however, a client can be diagnosed with depression during this time so that needed treatment will not be delayed.

● MDD can be further diagnosed in the DSM-5 with a more specific classification (specifier), including the following.

◯ Psychotic features: The presence of auditory hallucinations (such as voices telling the client they are sinful) or the presence of delusions (such as the client thinking that they have a fatal disease)

◯ Postpartum onset: A depressive episode that begins within 4 weeks of childbirth (known as postpartum depression) and can include delusions, which can put the newborn infant at high risk of being harmed by the mother

Seasonal�affective�disorder�(SAD): A form of depression that occurs seasonally, usually during the winter, when there is less daylight. Light therapy is the first-line treatment for SAD.

Persistent�Depressive�Disorder�(previously�known�as� dysrhythmic�disorder): A milder form of depression that usually has an early onset (in childhood or adolescence) and lasts at least 2 years for adults (1 year for children). Persistent depressive disorder contains at least three clinical findings of depression and can, later in life, become major depressive disorder.

Premenstrual�dysphoric�disorder�(PMDD): A depressive disorder associated with the luteal phase of the menstrual cycle. The prevalence of premenstrual dysphoric disorder is 2-6% of menstruating clients and causes problems that can be severe enough to interfere with the ability of a client to work or interact with others. Emotional manifestations can include mood swings, irritability, depression, anxiety, feeling overwhelmed, and difficulty concentrating. Physical manifestations can include lack of energy, overeating, hyper- or insomnia, breast tenderness, aching, bloating, and weight gain. Treatment includes exercise, diet, and relaxation therapy.

Substance-induced depressive disorder: Clinical findings of depression that are associated with the use of, or withdrawal from, drugs and alcohol.

CLIENT CARE Care of a client who has MDD will mirror the phase of the disease that the client is experiencing.

Acute phase: Severe clinical findings of depression ● Treatment is generally 6 to 12 weeks in duration. ● Potential need for hospitalization. ● Reduction of depressive manifestations is the goal

of treatment. ● Assess suicide risk, and implement safety precautions or

one-to-one observation as needed.

Continuation phase: Increased ability to function ● Treatment is generally 4 to 9 months in duration. ● Relapse prevention through education, medication

therapy, and psychotherapy is the goal of treatment.

Maintenance phase: Remission of manifestations ● This phase can last for years. ● Prevention of future depressive episodes is the goal

of treatment.

CHAPTER 13 Online Video: Understanding Major Depression

68 CHAPTER 13 DEPRESSIVE DISORDERS CONTENT MASTERY SERIES

ASSESSMENT

RISK FACTORS ● Family history and a previous personal history of

depression are the most significant risk factors. ● Depressive disorders are twice as common in females

than in males. ● Depression is very common among clients over age 65,

but the disorder is more difficult to recognize in the older adult client and can go untreated. It is important to differentiate between early dementia and depression. Some clinical findings of depression that can look like dementia are memory loss, confusion, and behavioral problems (social isolation or agitation). Clients can seek health care for somatic problems that are manifestations of untreated depression.

● Neurotransmitter deficiencies (a serotonin deficiency [affects mood, sexual behavior, sleep cycles, hunger, and pain perception] or a norepinephrine deficiency [affects attention and behavior]) can be risk factors for depression. Imbalances of the neurotransmitters norepinephrine, dopamine, acetylcholine, GABA, and possibly glutamate can play a role in the occurrence of depression.

OTHER RISK FACTORS ● Stressful life events ● Presence of a medical illness ● A client’s postpartum period ● Comorbid anxiety or personality disorder ● Comorbid substance use disorder ● Trauma occurring early in life

Depressive disorders occur throughout all groups of people.

Depression can be the primary disorder or a response to another physical or mental health disorder.

EXPECTED FINDINGS ● Anergia (lack of energy) ● Anhedonia (lack of pleasure in normal activities) ● Anxiety ● Reports of sluggishness (most common), or feeling

unable to relax and sit still ● Vegetative findings, which include a change in eating

patterns (usually anorexia in MDD; increased intake in persistent depressive disorder and PMDD), change in bowel habits (usually constipation), sleep disturbances, and decreased interest in sexual activity

● Somatic reports (fatigue, gastrointestinal changes, pain)

PHYSICAL ASSESSMENT FINDINGS ● The client most often looks sad with blunted affect. ● The client exhibits poor grooming and lack of hygiene. ● Psychomotor retardation (slowed physical

movement, slumped posture) is more common, but psychomotor agitation (restlessness, pacing, finger tapping) can also occur.

● The client becomes socially isolated, showing little or no effort to interact.

● Slowed speech, decreased verbalization, delayed response: The client might seem too tired to speak and can sigh often.

STANDARDIZED SCREENING TOOLS ● Hamilton Depression Scale ● Beck Depression Inventory ● Geriatric Depression Scale (short form) ● Zung Self-Rating Depression Scale ● Patient Health Questionnaire-9 (PHQ-9)

PATIENT-CENTERED CARE

NURSING CARE

Milieu therapy

Suicide risk: Assess the client’s risk for suicide, and implement appropriate safety precautions.

Self-care: Monitor the client’s ability to perform activities of daily living, and encourage independence as much as possible.

Communication: Relate therapeutically to the client who is unable or unwilling to communicate. ● Make time to be with the client, even if they do not speak. ● Make observations rather than asking direct questions,

which can cause anxiety in the client. For example, the nurse might say, “I noticed that you attended the unit group meeting today,” rather than asking, “Did you enjoy the group meeting?” Give directions in simple, concrete sentences because a client who has depression can have difficulty focusing on and comprehending long sentences.

● Give the client sufficient time to respond when holding a conversation due to a possible delayed response time.

Maintenance of a safe environment

Counseling: This can include individual counseling to assist with the following. ● Problem-solving ● Increasing coping abilities ● Changing negative thinking to positive ● Increasing self-esteem ● Assertiveness training ● Using available community resources

MEDICATIONS CLIENT TEACHING FOR ALL ANTIDEPRESSANTS ● Do not discontinue medication suddenly. ● Therapeutic effects are not immediate, and it can take

several weeks or more to reach full therapeutic benefits. ● Avoid hazardous activities (driving or operating heavy

equipment/machinery) due to the potential adverse effect of sedation.

● Notify the provider of any thoughts of suicide. ● Avoid alcohol while taking an antidepressant.

RN MENTAL HEALTH NURSING CHAPTER 13 DEPRESSIVE DISORDERS 69

Selective serotonin reuptake inhibitors (SSRIs)

Citalopram Fluoxetine Sertraline Leading treatment for depression

CLIENT EDUCATION ● Adverse effects can include nausea, headache, and central

nervous system stimulation (agitation, insomnia, anxiety). ● Be aware that sexual dysfunction can occur, and notify

provider if effects are intolerable. ● Observe for manifestations of serotonin syndrome. If any

occur, withhold the medication and notify the provider. ● Avoid the concurrent use of St. John’s wort, which can

increase the risk of serotonin syndrome. ● Follow a healthy diet and exercise regimen because

weight gain can occur with long-term use.

Tricyclic antidepressants

Amitriptyline

CLIENT EDUCATION ● Change positions slowly to minimize dizziness from

orthostatic hypotension. ● To minimize anticholinergic effects, chew sugarless

gum, eat foods high in fiber, and increase fluid intake to 2 to 3 L/day from food and beverage sources.

Monoamine oxidase inhibitors

Phenelzine

CLIENT EDUCATION ● Due to the risk for hypertensive crisis, avoid foods with

tyramine (ripe avocados or figs, fermented or smoked meats, liver, dried or cured fish, most cheeses, some beer and wine, and protein dietary supplements).

● Due to the risk of medication interactions, avoid all medications, including over-the-counter, without first discussing them with the provider.

Atypical antidepressants

Bupropion

CLIENT EDUCATION ● Observe for headache, dry mouth, GI distress, constipation,

increased heart rate, nausea, restlessness, or insomnia, and notify the provider if they become intolerable.

● Monitor food intake and weight due to appetite suppression.

● Avoid administering if at risk for seizures.

Serotonin norepinephrine reuptake inhibitors

Venlafaxine Duloxetine

NURSING ACTIONS ● Adverse effects include nausea, insomnia, weight gain,

diaphoresis, and sexual dysfunction. ● Caution in administering to clients who have a history

of hypertension.

ALTERNATIVE OR COMPLEMENTARY THERAPIES

St. John’s wort

A plant product (Hypericum perforatum), not regulated by the U.S. Food and Drug Administration, is taken by some individuals to relieve manifestations of mild depression.

NURSING ACTIONS ● Adverse effects include photosensitivity, skin rash,

rapid heart rate, gastrointestinal distress, and abdominal pain.

● St. John’s wort can increase or reduce levels of some medications if taken concurrently. The client should inform the provider if taking St. John’s wort.

! Medication interactions: Potentially fatal serotonin syndrome can result if St. John’s wort is taken with SSRIs or other types of antidepressants. Foods containing tyramine should be avoided.

Light therapy ● First-line treatment for SAD, light therapy inhibits

nocturnal secretion of melatonin. ● Exposure of the face to 10,000-lux light box 30 min/day,

once or in two divided doses

THERAPEUTIC PROCEDURES

Electroconvulsive therapy

Can be useful for some clients who have a depressive disorder and are unresponsive to other treatments.

NURSING ACTIONS: A specially trained nurse is responsible for monitoring the client before and after this therapy.

Transcranial magnetic stimulation

Uses electromagnetic stimulation (MRI strength magnetic pulsation) to stimulate focal areas of cerebral cortex. It is indicated for depressive disorders that are resistant to other forms of treatment.

Vagus nerve stimulation

Uses an implanted device that stimulates the vagus nerve. It can be used for clients who have depression that is resistant to antidepressant medications.

INTERPROFESSIONAL CARE Psychotherapy by a trained therapist can include individual cognitive-behavioral therapy (CBT), interpersonal therapy (IPT), group therapy, and family therapy. ● CBT assists the client to identify and change negative

behavior and thought patterns. ● IPT encourages the client to focus on personal

relationships that contribute to the depressive disorder.

70 CHAPTER 13 DEPRESSIVE DISORDERS CONTENT MASTERY SERIES

CLIENT EDUCATION Continuation phase followed by maintenance phase ● Review manifestations of depression with the client and

family members in order to identify relapse. ● Reinforce intended effects and potential adverse effects

of medication. ● Explain the benefits of adherence to therapy. ● Thirty minutes of exercise daily for 3 to 5 days each

week improves clinical findings of depression and can help to prevent relapse. Even shorter intervals of exercise are helpful. Exercise should be regarded as an adjunct to other therapies for the client who has major depressive disorder.

Active Learning Scenario

A nurse working in an acute mental health facility is performing an admission assessment for a client who has major depressive disorder (MDD). Use the ATI Active Learning Template: System Disorder to complete this item.

ALTERATION IN HEALTH (DIAGNOSIS)

EXPECTED FINDINGS: Identify at least four expected findings.

NURSING CARE: Describe an appropriate communication technique to relate therapeutically with this client.

Application Exercises

1. A nurse is caring for a client who has major depressive disorder. Which of the following should the nurse identify as a risk factor for depression? (Select all that apply.)

A. Male sex

B. History of chronic bronchitis

C. Recent death in client’s family

D. Family history of depression

E. Personal history of panic disorder

2. A nurse working on an acute mental health unit is admitting a client who has major depressive disorder and comorbid anxiety disorder. Which of the following actions is the nurse’s priority?

A. Placing the client on one-to-one observation

B. Assisting the client to perform ADLs

C. Encouraging the client to participate in counseling

D. Teaching the client about medication adverse effects

3. A nurse is teaching a client who has a new diagnosis of premenstrual dysphoric disorder (PMDD). Which of the following statements by the client indicates understanding of the teaching?

A. “I can expect my problems with PMDD to be worst when I’m menstruating.”

B. “I should avoid exercising when I am feeling depressed.”

C. “I am aware that my PMDD causes me to have rapid mood swings.”

D. “I should increase my caloric intake with a nutritional supplement when my PMDD is active.”

4. A charge nurse is discussing the care of a client who has major depressive disorder (MDD) with a newly licensed nurse. Which of the following statements by the newly licensed nurse indicates an understanding of the teaching?

A. “Care during the continuation phase focuses on treating continued manifestations of MDD.”

B. “The treatment of MDD during the maintenance phase lasts for 6 to 12 weeks.”

C. “The client is at greatest risk for suicide during the first weeks of an MDD episode.”

D. “Medication and psychotherapy are most effective during the acute phase of MDD.”

5. A nurse is interviewing a client who has a new diagnosis of persistent depressive disorder. Which of the following findings should the nurse expect?

A. Wide fluctuations in mood

B. Report of a minimum of five clinical findings of depression

C. Presence of manifestations for at least 2 years

D. Inflated sense of self-esteem

RN MENTAL HEALTH NURSING CHAPTER 13 DEPRESSIVE DISORDERS 71

Application Exercises Key

1. A. Females are twice as likely as males to experience a depressive disorder.

B. CORRECT: Depressive disorders are more common in a client who has a chronic medical condition.

C. CORRECT: Depressive disorders are more likely to occur in a client who is experiencing a high amount of stress (when grieving the death of a family member).

D. CORRECT: Depressive disorders are more likely to occur in a client whose has a family history of depression.

E. CORRECT: A history of an anxiety or personality disorder increases a client’s risk for depressive disorder.

NCLEX® Connection: Health Promotion and Maintenance, Health Promotion/Disease Prevention

2. A. CORRECT: The greatest risk for a client who has MDD and comorbid anxiety is injury due to self-harm. The highest priority intervention is placing the client on one-to-one observation.

B. The client who has MDD can require assistance with ADLs. However, this does not address the greatest risk to the client and is therefore not the priority intervention.

C. Encourage the client who has MDD to participate in counseling. However, this does not address the greatest risk to the client and is therefore not the priority intervention.

D. Teach the client who has MDD about medication adverse effects. However, this does not address the greatest risk to the client and is therefore not the priority intervention.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

3. A. Clinical findings of PMDD are present during the luteal phase of the menstrual cycle just prior to menses.

B. Aerobic and other exercise are effective treatments for depressive disorders, including PMDD.

C. CORRECT: A clinical finding of PMDD is emotional lability. The client can experience rapid changes in mood.

D. PMDD increases the client’s risk for weight gain due to overeating. It is not appropriate to increase caloric intake.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

4. A. The focus of the continuation phase is relapse prevention. Treatment of manifestations occurs during the acute phase of MDD.

B. The maintenance phase of treatment for MDD can last for 1 year or more.

C. CORRECT: The client is at greatest risk for suicide during the acute phase of MDD.

D. Medication therapy and psychotherapy are used during the continuation phase to prevent relapse of MDD.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

5. A. Wide fluctuations in mood are associated with bipolar disorder.

B. MDD contains a minimum of five clinical findings of depression.

C. CORRECT: Manifestations of persistent depressive disorder last for at least 2 years in adults.

D. A decreased, rather than inflated, sense of self-esteem is associated with persistent depressive disorder.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): MDD is a single episode or recurrent episodes of unipolar depression resulting in a significant change in a client’s normal functioning (social, occupational, self-care) accompanied by at least five clinical findings of MDD, which must occur almost every day for a minimum of 2 weeks, and last most of the day.

EXPECTED FINDINGS ● Depressed mood ● Difficulty sleeping or excessive sleeping ● Indecisiveness ● Decreased ability to concentrate ● Suicidal ideation ● Increase or decrease in motor activity ● Inability to feel pleasure (anhedonia) ● Increase or decrease in weight of more than 5% of total body weight over 1 month

NURSING CARE ● Make time to be with the client even if they don’t speak. ● Communicate with observations rather than asking direct questions. ● Give directions in simple, concrete sentences. ● Allow the client sufficient time to verbally respond.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

72 CHAPTER 13 DEPRESSIVE DISORDERS CONTENT MASTERY SERIES

RN MENTAL HEALTH NURSING CHAPTER 14 BIPOLAR DISORDERS 73

UNIT 3 PSYCHOBIOLOGIC DISORDERS

CHAPTER 14 Bipolar Disorders Bipolar disorders are mood disorders with recurrent episodes of depression and mania.

Bipolar disorders usually emerge in early adulthood, but early-onset bipolar disorder can be diagnosed in pediatric clients. Because manifestations can mimic expected findings of attention deficit hyperactivity disorder (ADHD), it is more difficult to assess and diagnose bipolar disorders in children than in other client age groups.

Periods of normal functioning alternate with periods of illness, though some clients are not able to maintain full occupational and social functioning. Clients can exhibit psychotic, paranoid, and/or bizarre behavior during periods of mania.

CLIENT CARE Care of a client who has bipolar disorder will mirror the phase of the disease that the client is experiencing.

Acute phase: Acute mania ● Hospitalization can be required. ● Reduction of mania and client safety are the goals

of treatment. ● Risk of harm to self or others is determined. ● One-to-one supervision can be indicated for

client safety.

Continuation phase: Remission of manifestations ● Treatment is generally 4 to 9 months in duration. ● Relapse prevention through education, medication

adherence, and psychotherapy is the goal of treatment.

Maintenance phase: Increased ability to function ● Treatment generally continues throughout the

client’s lifetime. ● Prevention of future manic episodes is the goal

of treatment.

BEHAVIORS SHOWN WITH BIPOLAR DISORDERS Mania: An abnormally elevated mood, which can also be described as expansive or irritable; usually requires hospitalization. Manic episodes last at least 1 week. (See the ASSESSMENT section in this chapter for specific findings.)

Hypomania: A less severe episode of mania that lasts at least 4 days accompanied by three or more manifestations of mania. Hospitalization is not required, and the client who has hypomania is less impaired. Hypomania can progress to mania.

Rapid cycling: Four or more episodes of hypomania or acute mania within 1 year and associated with increase recurrence rate and resistance to treatment.

TYPES OF BIPOLAR DISORDERS Bipolar I disorder: The client has at least one episode of mania alternating with major depression.

Bipolar II disorder: The client has one or more hypomanic episodes alternating with major depressive episodes.

Cyclothymic disorder: The client has at least 2 years of repeated hypomanic manifestations that do not meet the criteria for hypomanic episodes alternating with minor depressive episodes.

COMORBIDITIES ● Substance use disorder ● Anxiety disorders ● Borderline personality disorder ● Oppositional defiant disorder ● Social phobia and specific phobias ● Seasonal affective disorder ● Attention deficit hyperactivity disorder ● Migraines ● Metabolic syndrome

ASSESSMENT

RISK FACTORS Genetics: having an immediate family member who has a bipolar disorder

Physiological: neurobiologic and neuroendocrine disorders

Environmental: Increased stress in the environment can trigger mania and depression and increase risk for severe manifestations in genetically-susceptible children.

RELAPSE ● Use of substances (alcohol, cocaine, caffeine) can lead to

an episode of mania. ● Sleep disturbances can come before, be associated with,

or be brought on by an episode of mania. ● Psychological stressors can trigger an episode of mania.

CHAPTER 14 Online Video: Understanding Bipolar Disorder

74 CHAPTER 14 BIPOLAR DISORDERS CONTENT MASTERY SERIES

EXPECTED FINDINGS MANIC CHARACTERISTICS ● Labile mood with euphoria ● Agitation and irritability ● Restlessness ● Dislike of interference and intolerance of criticism ● Increase in talking and activity ● Flight of ideas: rapid, continuous speech with sudden

and frequent topic change ● Grandiose view of self and abilities (grandiosity) ● Impulsivity: spending money, giving away money

or possessions ● Demanding and manipulative behavior ● Distractibility and decreased attention span ● Poor judgment ● Attention-seeking behavior: flashy dress and makeup,

inappropriate behavior ● Impairment in social and occupational functioning ● Decreased sleep ● Neglect of ADLs, including nutrition and hydration ● Possible presence of delusions and hallucinations ● Denial of illness

DEPRESSIVE CHARACTERISTICS ● Flat, blunted, labile affect ● Tearfulness, crying ● Lack of energy ● Anhedonia: loss of pleasure and lack of interest in

activities, hobbies, sexual activity ● Physical reports of discomfort/pain ● Difficulty concentrating, focusing, problem-solving ● Self-destructive behavior, including suicidal ideation ● Decrease in personal hygiene ● Loss or increase in appetite and/or sleep, disturbed sleep ● Psychomotor retardation or agitation

STANDARDIZED SCREENING TOOL Mood Disorders Questionnaire: A standardized tool that places mood progression on a continuum from hypomania (euphoria) to acute mania (extreme irritability and hyperactivity) to delirious mania (completely out of touch with reality).

PATIENT-CENTERED CARE

NURSING CARE The care of the client is based on the phase of bipolar disorder that the client is experiencing. Nursing care is provided throughout this process.

Acute manic episode

Focus is on safety and maintaining physical health.

THERAPEUTIC MILIEU (within acute care mental health facility)

● Provide a safe environment during the acute phase. ● Assess the client regularly for suicidal thoughts,

intentions, and escalating behavior.

● Decrease stimulation without isolating the client if possible. Be aware of noise, music, television, and other clients, all of which can lead to an escalation of the client’s behavior. In certain cases, seclusion might be the only way to safely decrease stimulation for the client.

● Follow agency protocols for providing client protection (restraints, seclusion, one-to-one observation) if a threat of self-injury or injury to others exists.

● Implement frequent rest periods. ● Provide outlets for physical activity. Do not involve the

client in activities that last a long time or that require a high level of concentration and/or detailed instructions.

● Protect client from poor judgment and impulsive behavior, such as giving money away and sexual indiscretions.

MAINTENANCE OF SELF-CARE NEEDS ● Monitoring sleep, fluid intake, and nutrition. ● Providing portable, nutritious food because the client

might not be able to sit down to eat. ● Supervising choice of clothes. ● Giving step-by-step reminders for hygiene and dress.

COMMUNICATION ● Use a calm, matter-of-fact, specific approach. ● Give concise explanations. ● Provide for consistency with expectations and

limit-setting. ● Avoid power struggles, and do not react personally to

the client’s comments. ● Listen to and act on legitimate client grievances. ● Reinforce nonmanipulative behaviors. ● Use therapeutic communication techniques

MEDICATIONS Mood stabilizers

● Lithium carbonate ● Anticonvulsants that act as mood stabilizers: valproate

and carbamazepine treat acute mania; lamotrigine is used for maintenance therapy in bipolar mania.

First-generation antipsychotic medications: include chlorpromazine and loxapine

Second-generation antipsychotic medications: including olanzapine, risperidone, and others. Lurasidone and quetiapine are approved to treat depression in bipolar disorder.

Antidepressants: such as the SSRI fluoxetine, used to manage a major depressive episode

THERAPEUTIC PROCEDURES Electroconvulsive�therapy�(ECT): Can be used to moderate extreme manic behavior, especially when pharmacological therapy (lithium) has not worked. Clients who are suicidal or those who have rapid cycling can also benefit from ECT.

RN MENTAL HEALTH NURSING CHAPTER 14 BIPOLAR DISORDERS 75

CLIENT EDUCATION ● Case management to provide follow-up for the client

the family ● Group, family, and individual psychotherapy

(cognitive-behavior therapy) to improve problem-solving and interpersonal skills

HEALTH TEACHING ● The chronicity of the disorder requiring long-term

pharmacological and psychological support ● Benefits of psychotherapy and support groups to

prevent relapse ● Indications of impending relapse and ways to manage

the crisis ● Precipitating factors of relapse (sleep disturbance, use of

alcohol or caffeine) ● Importance of maintaining a regular sleep, meal, and

activity pattern ● Medication administration and adherence

COMPLICATIONS Physical exhaustion and possible death: A client in a true manic state usually will not stop moving, and does not eat, drink, or sleep. This can become a medical emergency.

NURSING ACTIONS ● Prevent client self-harm. ● Decrease client’s physical activity. ● Ensure adequate fluid and food intake. ● Promote an adequate amount of sleep each night. ● Assist the client with self-care needs. ● Manage medication appropriately.

Active Learning Scenario

A nurse in an acute mental health facility is caring for a client who is experiencing acute mania. Use the ATI Active Learning Template: System Disorder to complete this item to include the following.

ALTERATION IN HEALTH (DIAGNOSIS)

EXPECTED FINDINGS: Identify four expected findings.

NURSING CARE: Identify two nursing actions.

CLIENT EDUCATION: Identify two client outcomes.

Application Exercises

1. A nurse is planning care for a client who has bipolar disorder and is experiencing a manic episode. Which of the following interventions should the nurse include in the plan of care? (Select all that apply.)

A. Provide flexible client behavior expectations.

B. Offer concise explanations.

C. Establish consistent limits.

D. Disregard client concerns.

E. Use a firm approach with communication.

2. A nurse is teaching a newly licensed nurse about the use of electroconvulsive therapy (ECT) for the treatment of bipolar disorder. Which of the following statements by the newly licensed nurse indicates understanding?

A. “ECT is the recommended initial treatment for bipolar disorder.”

B. “ECT is contraindicated for clients who have suicidal ideation.”

C. “ECT is effective for clients who are experiencing severe mania.”

D. “ECT is prescribed to prevent relapse of bipolar disorder.”

3. A nurse is caring for a client who has bipolar disorder. Which of the following is the priority nursing action?

A. Set consistent limits for expected client behavior.

B. Administer prescribed medications as scheduled.

C. Provide the client with step-by-step instructions during hygiene activities.

D. Monitor the client for escalating behavior.

4. A nurse is caring for a client who has bipolar disorder. The client states, “I am very rich, and I feel I must give my money to you.” Which of the following responses should the nurse make?

A. “Why do you think you feel the need to give money away?”

B. “I am here to provide care and cannot accept this from you.”

C. “I can request that your case manager discuss appropriate charity options with you.”

D. “You should know that giving away your money is inappropriate.”

5. A nurse is discussing relapse prevention with a client who has bipolar disorder. Which of the following information should the nurse include in the teaching? (Select all that apply.)

A. Use caffeine in moderation to prevent relapse.

B. Difficulty sleeping can indicate a relapse.

C. Begin taking your medications as soon as a relapse begins.

D. Participating in psychotherapy can help prevent a relapse.

E. Anhedonia is a clinical manifestation of a depressive relapse.

76 CHAPTER 14 BIPOLAR DISORDERS CONTENT MASTERY SERIES

Application Exercises Key

1. A. Establish consistent client behavior expectations to decrease the risk for client manipulation.

B. CORRECT: Offering concise explanations improves the client’s ability to focus and comprehend the information.

C. CORRECT: Establishing consistent limits decreases the risk for client manipulation.

D. Respond to valid client concerns to foster a trusting nurse-client relationship.

E. CORRECT: Using a firm approach with client communication promotes structure and minimizes inappropriate client behaviors.

NCLEX® Connection: Psychosocial Integrity, Behavioral Interventions

2. A. Pharmacological intervention is the recommended initial treatment for bipolar disorder.

B. ECT is effective for clients who have bipolar disorder and suicidal ideation.

C. CORRECT: ECT is appropriate for the treatment of severe mania associated with bipolar disorder.

D. ECT is prescribed for clients experiencing an acute episode of bipolar disorder rather than for the prevention of relapse.

NCLEX® Connection: Reduction of Risk Potential, Potential for Complications of Diagnostic Tests/Treatments/Procedures

3. A. Set consistent limits for expected client behavior. However, this does not address the client’s priority need for safety and is therefore not the priority action.

B. Administer prescribed medications as scheduled. However, this does not address the client’s priority need for safety and is therefore not the priority action.

C. Provide the client with step-by-step instructions during hygiene activities. However, this does not address the client’s priority need for safety and is therefore not the priority action.

D. CORRECT: Monitoring for escalating behavior addresses the client’s priority need for safety and is therefore the priority nursing action.

NCLEX® Connection: Psychosocial Integrity, Mental Health Concepts

4. A. Asking a “why” question is a nontherapeutic form of communication and can promote a defensive client response.

B. CORRECT: This statement is matter-of-fact and concise and is a therapeutic response to a client who has bipolar disorder.

C. This statement does not recognize the possibility of poor judgment, which is associated with bipolar disorder.

D. This statement offers disapproval and can be interpreted by the client as aggressive, which can promote a defensive client response.

NCLEX® Connection: Psychosocial Integrity, Therapeutic Communication

5. A. The client who has bipolar disorder should avoid the use of caffeine because it can precipitate a relapse.

B. CORRECT: The client should be alert for sleep disturbances, which can indicate a relapse.

C. The client who has bipolar disorder should take prescribed medications to prevent and minimize a relapse.

D. CORRECT: The client who has bipolar disorder can participate in psychotherapy to help prevent a relapse.

E. CORRECT: The onset of anhedonia, the inability to feel pleasure, is a manifestation of depression which can indicate a relapse of bipolar disorder.

NCLEX® Connection: Physiological Adaptation, Illness Management

Active Learning Scenario Key

Using the ATI Active Learning Template: System Disorder

ALTERATION IN HEALTH (DIAGNOSIS): An abnormally elevated mood, which can also be described as expansive or irritable; usually requires hospitalization

EXPECTED FINDINGS ● Agitation and irritability ● Intolerance of interference or criticism ● Increase in talking and activity ● Flight of ideas ● Grandiosity ● Impulsivity ● Demanding and manipulative behavior ● Distractibility ● Poor judgment ● Attention-seeking behavior ● Impairment in social and occupational functioning ● Decreased sleep ● Neglect of ADLs ● Possible delusions and hallucinations ● Denial of illness

NURSING CARE ● Focus on safety as the priority of care. ● Maintain client’s physical health and self-care needs. ● Provide a safe environment. ● Assess for suicidal thoughts, intentions, and escalating behavior. ● Decrease stimulation. ● Provide client protection with restraints, seclusion,

or one-to-one observation if necessary. ● Implement frequent rest periods. ● Provide appropriate outlets for physical activity. ● Use calm and concise communication.

CLIENT EDUCATION: Client outcomes ● The client will refrain from self-harm. ● The client will sleep 6 to 8 hr each night. ● The client will maintain adequate fluid and food intake. ● The client will use appropriate communication skills to meet needs. ● The client will participate in self-care.

NCLEX® Connection: Psychosocial Integrity, Crisis Intervention

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RN MENTAL HEALTH NURSING CHAPTER 15 PSYCHOTIC DISORDERS 77

UNIT 3 PSYCHOBIOLOGIC DISORDERS

CHAPTER 15 Psychotic Disorders Schizophrenia spectrum and other psychotic disorders affect thinking, behavior, emotions, and the ability to perceive reality. Schizophrenia probably results from a combination of genetic, neurobiological, and nongenetic (injury at birth, viral infection, and nutritional) factors.

The typical age at onset is late teens and early 20s, but schizophrenia has occurred in young children and can begin in later adulthood. A prodromal period can occur during which the client experiences negative symptoms (anergia) or a reduced level of positive symptoms. Psychotic disorders become problematic when manifestations interfere with interpersonal relationships, self-care, and ability to work.

TYPES OF DISORDERS The various types of psychotic disorders recognized and defined by the DSM-5 include the following.

Schizophrenia: The client has psychotic thinking or behavior present for at least 6 months. Areas of functioning, including school or work, self-care, and interpersonal relationships, are significantly impaired.

Schizotypal personality disorder: The client has impairments of personality (self and interpersonal) functioning. However, impairment is not as severe as with schizophrenia.

Delusional disorder: The client experiences delusional thinking for at least 1 month. Self or interpersonal functioning is not markedly impaired.

Brief psychotic disorder: The client has psychotic manifestations that last 1 day to 1 month in duration.

Schizophreniform disorder: The client has manifestations similar to schizophrenia, but the duration is 1 to 6 months, and social/occupational dysfunction might not be apparent.

Schizoaffective�disorder: The client’s disorder meets the criteria for both schizophrenia and depressive or bipolar disorder.

Substance-induced psychotic disorder: The client experiences psychosis due to substance intoxication or withdrawal. However, the psychotic manifestations are more severe than typically expected.

Psychotic or catatonic disorder not otherwise specified: The client exhibits psychotic features (impaired reality testing) or bizarre behavior (psychotic) or a significant change in motor activity behavior (catatonic) but does not meet criteria for diagnosis with another specific psychotic disorder.

ASSESSMENT

EXPECTED FINDINGS

Characteristic dimensions of psychotic disorders

POSITIVE SYMPTOMS: Manifestation of things that are not normally present. These are the most easily identified manifestations.

● Hallucinations ● Delusions ● Alterations in speech ● Bizarre behavior (walking backward constantly)

NEGATIVE SYMPTOMS: Absence of things that are normally present. These manifestations are more difficult to treat successfully than positive symptoms. ● Affect:�Usually blunted (narrow range of expression) or

flat (facial expression never changes) ● Alogia: Poverty of thought or speech. The client might

sit with a visitor but only mumble or respond vaguely to questions.

● Anergia: Lack of energy ● Anhedonia: Lack of pleasure or joy. The client is

indifferent to things that often make others happy, such as looking at beautiful scenery.

● Avolition: Lack of motivation in activities and hygiene. For example, the client completes an assigned task, such as making their bed, but is unable to start the next common chore without prompting.

COGNITIVE FINDINGS: Problems with thinking make it very difficult for the client to live independently.

● Disordered thinking ● Inability to make decisions ● Poor problem-solving ability ● Difficulty concentrating to perform tasks ● Short term memory deficits ● Impaired abstract thinking

AFFECTIVE FINDINGS: Manifestations involving emotions ● Hopelessness ● Suicidal ideation ● Unstable or rapidly changing mood

Alterations in thought (delusions)

Alterations in thought are false fixed beliefs that cannot be corrected by reasoning and are usually bizarre. These include the following.

● Ideas of reference: Misconstrues trivial events and attaches personal significance to them, such as believing that others, who are discussing the next meal, are talking about him

● Persecution: Feels singled out for harm by others, such as being hunted down by the FBI

CHAPTER 15

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78 CHAPTER 15 PSYCHOTIC DISORDERS CONTENT MASTERY SERIES

● Grandeur: Believes that they are all powerful and important, like a god

● Somatic delusions: Believes that their body is changing in an unusual way, such as growing a third arm

● Jealousy: Believes that their partner is sexually involved with another individual even though there is not any factual basis for this belief

● Being controlled: Believes that a force outside their body is controlling him

● Thought broadcasting: Believes that their thoughts are heard by others

● Thought insertion: Believes that others’ thoughts are being inserted into their mind

● Thought withdrawal: Believes that their thoughts have been removed from their mind by an outside agency

● Religiosity: Is obsessed with religious beliefs ● Magical thinking: Believes their actions or thoughts

are able to control a situation or affect others, such as wearing a certain hat makes them invisible to others

Alterations in speech

The following examples can occur. ● Associative looseness: Unconscious inability to

concentrate on a single thought. Can progress to flight of ideas in which the client’s speech moves so rapidly from one thought to another that it is incoherent.

● Neologisms: Made-up words that have meaning only to the client (“I tranged and flittled.”).

● Echolalia: The client repeats the words spoken to him. ● Clang association: Meaningless rhyming of words, often

forceful, such as, “Oh fox, box, and lox.” ● Word salad: Words jumbled together with little meaning

or significance to the listener (“Hip hooray, the flip is cast and wide-sprinting in the forest.”).

Alterations in perception

Hallucinations are sensory perceptions that do not have any apparent external stimulus. Examples include:

● Auditory: Hearing voices or sounds ◯ Command: The voice instructs the client to perform an action (to hurt self or others).

● Visual: Seeing persons or things ● Olfactory: Smelling odors ● Gustatory: Experiencing tastes ● Tactile: Feeling bodily sensations

Personal boundary difficulties

Disenfranchisement with one’s own body, identity, and perceptions. This includes the following. ● Depersonalization: Nonspecific feeling that a client has

lost their identity. Self is different or unreal. ● Derealization: Perception that the environment has

changed, such as the client believing that objects in their environment are shrinking.

● Illusions: Misperceptions or misinterpretations of a real experience

Alterations in behavior ● Extreme agitation, including pacing and rocking ● Stereotyped behaviors: Motor patterns that had

meaning to client (sweeping the floor) but now are mechanical and lack purpose

● Automatic obedience: Responding in a robot-like manner ● Waxy�flexibility: Maintaining a specific position for an

extended period of time ● Stupor: Motionless for long periods of time, coma-like ● Negativism: Doing the opposite of what is requested ● Echopraxia: Purposeful imitation of movements

made by others ● Catatonia: Pronounced decrease or increase in the

amount of movement. Muscular rigidity, or catalepsy, may be so severe that limbs may be so severe that the limbs remain in whatever position they are placed.

● Motor retardation: Pronounced slowing of movement ● Impaired impulse control: Reduced ability to

resist impulses ● Gesturing or posturing: Assuming unusual and illogical

expressions ● Boundary impairment: Impaired ability to see where

one person’s body ends and another’s begins

STANDARDIZED SCREENING TOOLS Abnormal�Involuntary�Movement�Scale�(AIMS): This tool is used to monitor involuntary movements and tardive dyskinesia in clients who take antipsychotic medication.

World Health Organization Disability Assessment Schedule (WHODAS): This scale helps to determine the client’s level of global functioning.

PATIENT-CENTERED CARE

NURSING CARE ● Milieu therapy is used for clients who have a psychotic

disorder both in acute men