Mental Health Nursing

1. Mental Health Nursing Elisa A. Mancuso RNC, MS, FNS Professor

2. Mental Health • Successful adaptation to internal & external stressors • age appropriate thoughts, feelings & behaviors • Adaptive Coping Mechanisms • + Self-Esteem • + Relationships • Reality oriented • Effective Problem Solver • Communicate effectively • Control emotions • Reason Logically • Risk Taker • Dynamic and adjust PRN

3. Mental Illness • Clinically significant behavioral pattern or psychological syndrome • Associated with distress or disability • ↑↑ Risk of suffering causing; • Loss of freedom • Isolation • Pain • Death

4. Mental Health-Illness Continuum Health ↔ Illness Reality Oriented Hallucinations Meaningful Work Disengaged Resilient Anhedonia

5. DSM IV-TRDiagnostic & Statistical Manual of Mental Disorders 4th ed, Text Revision • Taxonomy used to describe mental disorders according to specific criteria. • Multi-axial (Axis I-V) classification system Axis I - Clinical Disorders Axis II - Personality Disorders & Mental Retardation Axis III - General Medical Conditions Axis IV - Psychosocial & Environmental Problems Axis V - Global Assessment Functioning (GAF) [Psychological, social & occupational]

6. Psychological Theories • Psychoanalytic Model- Freud • Basic character formed by age 5. • Psychosexual stages of development. • Oral, Anal, Phallic, Latency & Genital • Behavior motivated by subconscious thoughts & feelings. • Ego defense mechanisms. • Neurotic symptoms are attempts to control anxiety. • Change is a process of insight. • Uncover the repressed feelings to resolve conflicts.

7. Psychoanalytic Model- Freud cont. • Personality Components: • Id: Pleasure Principle • Ego: Reality Principle • Superego: Perfection Principle • Conscious-Aware of present Here & Now • Subconscious - Not aware • Repressed feelings, thoughts

8. Psychoanalytic Model- Freud cont. • Transference • Feelings and attitudes patient had originally experienced in other relationships, now displaces onto the therapist. • Countertransference • Therapist displaces onto the patient attitudes or feelings from his past.

9. Developmental Model-Erikson • Social processes affect specific tasks for each stage and emotional growth. • Incorporates: Problem Solving, Decision Making, Coping & Communication • 8 Continuous and evolutionary stages • Trust vs. Mistrust • Autonomy vs. Shame/Doubt • Initiative vs. Guilt • Industry vs. Inferiority • Identity vs. Role Diffusion • Intimacy vs. Isolation • Generativity vs. Self-Absorption • Ego Integrity vs. Despair

10. Interpersonal Model - Sullivan • Behavior and personality development are direct result of interpersonal relationships. • Basic fear is rejection = ↑ anxiety • Therapeutic Milieu • Community environment which facilitates client interaction • Practice interpersonal skills • Work cooperatively to solve problems.

11. Humanistic Model- Maslow • Hierarchy of basic human needs • Physical • Safety/Security • Love & Belonging • Self-Esteem • Self-Actualization • Focus on client’s strength and potential to change • Present/Future oriented

12. Humanistic Model-Rogers • Client-centered therapy • Unconditioned positive regard for the client • Genuineness & empathetic understanding • Importance of learning • ↑ Potential • ↑ Personal Growth

13. Behavioral Model- Skinner & Pavlov Behaviorism • Focuses on behaviors and changes, not the mind’s effect. • All behavior is learned. • Behavior has consequences • Reward or Punishment • Reconditioning • Unlearning maladaptive behavior • Treatment Modalities • Behavior Modification • Token Economy • Systematic Desensitization

14. Behavioral Model- cont. Reinforcement • ↑ Frequency of behavior • (+) Reinforcement uses a stimulus • Praise for completed work • (-) Reinforcement removes the stimulus • No attention for interrupting • Continuous Reinforcement • Fastest way to ↑ behavior • Intermittent Reinforcement • Slower, but longer lasting way to ↑ behavior Punishment • ↓ Frequency of behavior • (+) Punishment = Scolding for inappropriate behavior • (-) Punishment = No contact with “wrong” crowd (↓ cursing)

15. Medical Model- Kraeplin • Disease Entity • Signs & Symptoms • Physiological ▲s and possibly viruses, altered immune system • PET scans √ brain metabolism • CT scans √ lesions, tumors • Classify illness via DSM-IV TR • Biochemical • ▲s in Neurotransmitters • ↑ DA = hallucinations & delusions • Drug therapy is effective • Genetic • Specific genes predispose to ↑ risk of illness • Chromosome # 5 & 6 ↑ risk of schizophrenia • Twins 50-75% risk

16. Cerebrum = 2 Hemispheres & 4 Lobes • L Hemisphere→ controls R side of body • Logical reasoning, reading, writing, math • R Hemisphere→ controls L side of body • Creative thinking, intuition, artistic abilities • Frontal Lobe • Thought, emotions, memories, movement & moral behavior • Parietal Lobe • Taste, touch , spatial orientation • Temporal Lobe • Smell, hearing, memory & emotional expression • Occipital Lobe • Language & visual interpretation

17. Brain Stem • Midbrain, Pons & Medulla Oblongata • Reticular Activating System (RAS) • Motor activity, sleep, consciousness & awareness • Extrapyramidal System (EPS) • Movement & coordination

18. Limbic System = Emotional Brain • Thalamus • Activity, sensation & emotion • Hypothalamus • Temp regulation, appetite control, sexual drive, & impulsive behavior (anger, rage, excitement) • Amygdala & Hippocampus • Emotional arousal & memory

19. Neurotransmitters • Dopamine (DA) Excites • Complex movements, motivation, cognition, • Emotional responses • ↑ DA – Schizophrenia • Norepinephrine (NE) Excites • Mood regulation, attention, learning, memory, • sleep, wakefulness • ↓ NE – depression • Epinephrine (E) Excites • Perception = Flight or Fight response

20. Neurotransmitters • Serotonin (5-HT) Inhibits • Appetite, sleep, arousal, pain perception, • Libido, regulation of emotions • ↓ 5-HT –Schizophrenia, Aggression & suicide • Gamma Aminobutyric Acid (GABA) Inhibits • Slows down other neurotransmitters • ↑ GABA - ↓ DA, G, NE, E, ACh • Glutamate (G) Excites • Acetylcholine (ACh) Excites/Inhibits • Sleep & arousal, pain perception & movement • ↓ ACh = confusion • Histamine (H) • Alertness, allergic response, gastric secretions,↑↑ wt.

21. Nursing Theory -Peplau • Interpersonal Therapeutic Model • Nurse-Patient Relationship (1:1) • Collaborative process • Nurse’s Role • Resource person, teacher, leader, surrogate, counselor Therapeutic Relationship Criteria • Patient initiated • Pt accepted unconditionally • Create environment of trust • RN conveys genuineness & empathy • Explore feelings, thoughts, behaviors & experiences • Identify alternate methods for problem solving

22. Therapeutic Relationship 4 Distinct Phases 1. Orientation • Orientation/Introduction • Establish trust and rapport • Identify purpose, roles and responsibilities • Assess client’s needs • Form contract

23. Working (Identification & Exploitation) 2. Identification • RN facilitates expression of feelings • Pt participates to identify problems • Pt responds and trusts RN 3. Exploitation • Promote Pt insights & perception of reality • Overcome resistant behaviors • Pt tests alternate problem solving & coping skills • Initiate action plan & new goals • ▲ from dependent→ independent behavior • ↑ skills in interpersonal relationships

24. 4. Resolution/Termination • Summarize work & growth accomplished • Review discharge plan & actions to deal with potential stressors • Referrals to community resources • Acknowledge feelings RT ending relationship

25. Therapeutic Communication • Active Listening • Be attentive to verbal & non-verbal messages. • Assess congruency of message • RN Non-Verbal Skills S - Sit squarely facing Pt O - Observe an open posture L - Lean forward toward the Pt. E - Establish eye contact R – Relax!

26. Non-Verbal Assessment • Physical Assessment • Clothing & Hygiene • Body Movement/Posture • Reflects self-esteem & status • Touch • Ellict both (+ & -) responses • Cultural interpretation • Facial Expression • Reflects affect • Eye Movement • “Windows of the soul” • ↑ Direct contact = personal interest • Vocal Cues • How a message is verbalized • Pitch, tone, loudness, rate of speaking

27. Communication Techniques • Acceptance • Non-judgmental attitude • Convey respect • Offering Self • Sense of presence • Being available • Open-ended Questions • Broad openings allow Pt to select the topics • Validation • Confirming what the patient has said

28. Communication Techniques • Reflection • Content & feeling is referred back to Pt • Pt recognition & acceptance • Restatement • Paraphrase main content or emotion • Focus • Direct conversation to a single concept • Clarification • Enhance understanding vague or confused message

29. Communication Techniques • Convey Information • Supply data via statement • Provide Feedback • Specific constructive information • State Observations • Verbalize what is witnessed or perceived • Connect Information • Identify relationships, similarities or differences to clarify behavior/ thoughts

30. Communication Techniques • Confrontation • Identify discrepancies between what the Pt says & does • Summarize • Highlight the main themes of content & feelings discussed • Present Reality • Orient to the present • Clarify misperceptions • Silence • Interaction without words

31. Blocks to Communication • False Reassurance • May discourage Pt from disclosing feelings • Rejecting • Refusing to consider the Pt’s ideas or behaviors • Giving Approval • Passing judgment or Pt “right or wrong” • Giving Advice • Implies RN knows what is best for the Pt. • Probe • Pushing for answers the Pt does not want to discuss

32. Blocks to Communication • Defend • Implies Pt has no right to express his own ideas • Belittle • Minimizing Pt. distress → Pt. unimportant • Change the Subject • RN takes over the direction of the conversation • Denial • Blocks further discussion 1/10