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Chapter
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6, 8
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10
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5
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If being a survivor is the main reason treatment has been sought, remember that the survivor, not
the deceased, is the patient. Focus on the patients thoughts and feelings, and do a thorough assessment
as you usually would.
If you are a friend or relative of a suicide survivor, remember that the most difficult time for
these survivors is not so much in the immediate aftermath of the suicide; rather, it is in the weeks,
months, and years following their loss. Make frequent efforts to reach out to these individuals,
especially on the most difficult anniversary dates. Do not be afraid of talking about the deceased
person; in fact, speak of them often. While this may seem counterintuitive and uncomfortable for most,
survivors of suicide universally want their loved one to be remembered in this way. Talking reduces
the hurt, isolation, and stigma.
If being a survivor comes out as an incidental finding during an assessment, ask open-ended
questions and evaluate how much the loss has been resolved.
Recommend community resources and survivor support groups and show empathy about the loss
of someone to suicide. Know about local Survivors of Suicide (SOS) support groups in your area, and
refer the survivors and their families as soon as possible following the suicide
(Halter 493)
These are things to say to a patient with suicidal ideations:
The nurse assesses whether the patient has a plan and the lethality of the plan.
The nurse tells the patient that this is serious, that the nurse does not want harm to come to the
patient, and that this information needs to be shared with other staff:
This is very serious, Mr. Lamb. I dont want any harm to come to you. Ill have to share this
with the other staff.
The nurse can then discuss with the patient the feelings and circumstances that led up to this
decision.
(Halter 139)
5. Normal psychosocial growth and development, nursing assessment and age considerations
Nursing Assessment:
to know that their records are private; they should receive an explanation as to
how information will be shared among the treatment team. Questions related to
such topics as substance abuse and sexual abuse demand confidentiality (Arnold &
Boggs, 2011); however, threats of suicide, homicide, sexual abuse, or behaviors
that put the patient or others at risk for harm must be shared with other
professionals, as well as with the parents. Because identifying risk factors is one of
the key objectives when assessing adolescents, it is helpful to use a brief,
structured interview technique such as the HEADSSS interview (Halter 118)
Older Adults: It is wise to identify any physical deficits at the onset of the
assessment and make accommodations for them. If the patient is hard of hearing,
speak a little more slowly in clear, louder tones (but not too loud), and seat the
patient close to you without invading his or her personal space. Often, a voice that
is lower in pitch is easier for older adults to hear, although a higher-pitched voice
may convey anxiety to some. Refer to Chapter 30 for more on assessing and
communicating with the older adult. (Halter 119)
Crisis intervention
g. Primary care
h. Secondary care
i. Tertiary care
7. Common types of boundary drifts and violations of patient rights
Two common circumstances in which boundaries are blurred are (1) when the relationship is allowed to
slip into a social context and (2) when the nurses needs (for attention, affection, and emotional support)
are met at the expense of the patients needs.
The most egregious boundary violations are those of a sexual nature (Wheeler, 2008). This type of
violation results in high levels of malpractice actions and the loss of professional licensure on the part of
the nurse.
-The cost of antipsychotic mediations can be a factor for some clients. Assess the need for case
management intervention.
(ATI p 221)
-Advise clients to take medication as prescribed on a regular schedule. (ATI p 217)
10. Understanding the link between mental illness and the immune system
-Acute stress can cause: Suppression of the immune system
Chronic stress can cause: Lowered resistance to infections, leading to increase in opportunistic viral and
bacterial infections
-There is an interaction between the nervous system and the immune system that occurs during the alarm
phase of the GAS
(Halter 169)
-Through the hypothalamic-pituitary-adrenal and sympathetic-adrenal medullary axes, can induce changes
in the immune system.
-There are links among stress (biopsychosocial), the immune system, and diseasea clear mind-body
connection that may alter health outcomes.
-Stress may result in malfunctions in the immune system that are implicated in autoimmune disorders,
immunodeficiency, and hypersensitivities.
(Halter 169-170)
Stress can enhance the immune system and prepare the body to respond to injury by fighting infections
and healing wounds. Immune cells normally release cytokines, which are proteins and glycoproteins
used for communication between cells, when a pathogen is detected; they serve to activate and recruit
other immune cells. During times of stress, these cytokines are released, and immunity is profoundly
activated, but the activation is limited since the cytokines stimulate further release of corticosteroids,
which inhibits the immune system.
(Halter 170)
11. Assessing and intervening with the patient during the 4 levels of anxiety
Levels of anxiety - As discussed in Chapter 2, Hildegard Peplau had a profound role in shaping the specialty of
psychiatric mental health nursing. She identified anxiety as one of the most important concepts and developed
an anxiety model that consists of four levels: mild, moderate, severe, and panic (Peplau, 1968). The boundaries
between these levels are not distinct, and the behaviors and characteristics of individuals experiencing anxiety
can and often do overlap. Identification of the specific level of anxiety is essential because interventions are
based on the degree of the patients anxiety.
Mild anxiety-Mild anxiety occurs in the normal experience of everyday living and allows an individual to
perceive reality in sharp focus. A person experiencing a mild level of anxiety sees, hears, and grasps more
information, and problem solving becomes more effective. Physical symptoms may include slight discomfort,
restlessness, irritability, or mild tension-relieving behaviors (e.g., nail biting, foot or finger tapping, fidgeting).
Moderate anxiety-As anxiety increases, the perceptual field narrows, and some details are excluded from
observation. The person experiencing moderate anxiety sees, hears, and grasps less information and may
demonstrate selective inattention, in which only certain things in the environment are seen or heard unless they
are pointed out. The ability to think clearly is hampered, but learning and problem solving can still take place
although not at an optimal level. Sympathetic nervous system symptoms begin to kick in. The individual may
experience tension, pounding heart, increased pulse and respiratory rate, perspiration, and mild somatic
symptoms (e.g., gastric discomfort, headache, urinary urgency). Voice tremors and shaking may be noticed.
Mild or moderate anxiety levels can be constructive because anxiety may be a signal that something in the
persons life needs attention or is dangerous (see the Case Study and Nursing Care Plan for moderate anxiety on
the Evolve website).
Severe anxiety-The perceptual field of a person experiencing severe anxiety is greatly reduced. A person with
severe anxiety may focus on one particular detail or many scattered details and have difficulty noticing what is
going on in the environment, even when another points it out. Learning and problem solving are not possible at
this level, and the person may be dazed and confused. Behavior is automatic and aimed at reducing or relieving
anxiety. Somatic symptoms (e.g., headache, nausea, dizziness, insomnia) often increase; trembling and a
pounding heart are common, and the person may experience hyperventilation and a sense of impending doom or
dread (see Case Study and Nursing Care Plan 15-1).
Panic-Panic is the most extreme level of anxiety and results in markedly disturbed behavior. Someone in a state
of panic is unable to process what is going on in the environment and may lose touch with reality. The behavior
that results may be manifested as pacing, running, shouting, screaming, or withdrawal. Hallucinations, or false
sensory perceptions (e.g., seeing people or objects not really there), may be experienced. Physical behavior may
become erratic, uncoordinated, and impulsive. Automatic behaviors are used to reduce and relieve anxiety
although such efforts may be ineffective. Acute panic may lead to exhaustion.
Defense mechanisms
Obsessive-Compulsive Disorders
Obsessions
o Thoughts, impulses, or images that persist and recur, so that they cannot be dismissed from the
mind
Compulsions
o Ritualistic behaviors an individual feels driven to perform in an attempt to reduce anxiety
Obsessive-Compulsive Disorders
(Cont.)
Obsessive-compulsive disorder
Body dysmorphic disorder
Hoarding disorder
Hair pulling and skin picking disorders
Cultural awareness
2.
Cultural knowledge
3.
Cultural encounters
4.
Cultural skill
5.
Cultural desire
16. Ethical principles that guide psychiatric nursing practice
Ethics is the study of philosophical beliefs about what is considered right or wrong in a society. The term
bioethics is the study of specific ethical questions that arise in health care. The five basic principles of bioethics
are:
1.
Beneficence: The duty to act to benefit or promote the good of others (e.g., spending extra time to help
calm an extremely anxious patient).
2.
Autonomy: Respecting the rights of others to make their own decisions (e.g., acknowledging the
patients right to refuse medication promotes autonomy).
3.
Justice: The duty to distribute resources or care equally, regardless of personal attributes (e.g., an ICU
nurse devotes equal attention to someone who has attempted suicide as to someone who suffered a brain
aneurysm).
4.
Fidelity (nonmaleficence): Maintaining loyalty and commitment to the patient and doing no wrong to
the patient (e.g., maintaining expertise in nursing skill through nursing education).
5.
Veracity: Ones duty to communicate truthfully (e.g., describing the purpose and side effects of
psychotropic medications in a truthful and non-misleading way). (Halter 99)
17. Legal issues in psychiatric practice??
Non therapeutic