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Tulsa Traditional N4043

Exam I Study Guide


Fall 2015
*Note- This is a study guide, not a test blueprint. The student is responsible for all content indicated in the course
modules.
Concept
Assertive community treatment
Medications, transmitters and receptors and in
which disease process it is involved
Psychosocial Theories, including Freud, Peplau,
Maslow, and cognitive restructuring
Nursing interventions in suicide, identifying
priority needs in suicidal patients
Normal psychosocial growth and development,
nursing assessment and age considerations
Nursing assessment in a crisis-types of crisis
Common types of boundary drifts and violations of
patient rights
Psychosocial Nursing process: Assessment,
Diagnosis, Outcome planning, Implementation and
Evaluation
The role of the nurse in supporting a patient with
medication compliance
Understanding the link between mental illness and
the immune system
Assessing and intervening with the patient during
the 4 levels of anxiety
Medications for treating anxiety
Defense mechanisms
Identifying Obsessive Compulsive behaviors
Components of culturally competent care
Ethical principles that guide psychiatric nursing
practice
Legal issues in psychiatric practice
Documentation of care
Therapeutic and non-therapeutic communication
techniques.
Actions of the various neurotransmitters
Neuroimaging tests that are helpful in psychiatry

Chapter
4
3
2
7

7
26
6, 8
7

3
10
15
15
15
15
5
6
6
6
9
3
3

1. Assertive community treatment

An intensive type of case management for people with serious, persistent


psychiatric symptoms. Repeated hospitalizations are reduced through a
multidisciplinary team that provides a comprehensive array of services.

2. Medications, transmitters and receptors and in which disease process it is involved

3. Psychosocial Theories, including Freud, Peplau, Maslow, and cognitive restructuring


Freud: Freud believed that human development proceeds through five stages from infancy to adulthood.
His main focus, however, was on events that occur during the first 5 years of life. From Freuds
perspective, experiences during the early stages determined an individuals lifetime adjustment patterns
and personality traits. In fact, Freud thought that personality was formed by the time the child entered
school and that subsequent growth consisted of elaborating on this basic structure. (Halter 21)
Peplau: Peplau was the first nurse to identify psychiatric mental health nursing both as an essential
element of general nursing and as a specialty area that embraces specific governing principles. She was
also the first nurse theorist to describe the nurse-patient relationship as the foundation of nursing
practice (Halter 25)
Maslow: Maslow conceptualized human motivation as a hierarchy of dynamic processes or needs that
are critical for the development of all humans. Central to his theory is the assumption that humans are
active rather than passive participants in life, striving for self-actualization. Maslow (1968) focused on
human need fulfillment, which he categorized into six incremental stages, beginning with physiological
survival needs and ending with self-transcendent needs (Halter 31)
Cognitive restructuring: Changing cognitive distortions can decrease anxiety. It assist clients to
identifiy negative thought that produce anxiety, examine the cause, and develop supportive ideas that
replace negative self-talk ATI pg. 56
Erikson: Erikson described development as occurring in eight predetermined and consecutive life stages
(psychosocial crises), each of which consists of two possible outcomes (e.g., industry vs. inferiority).
The successful or unsuccessful completion of each stage will affect the individuals progression to the
next (Halter 23)

4. Nursing interventions in suicide, identifying priority needs in suicidal patients


General Suicide Interventions include:
Suicide Prevention, Hope Instillation, Coping Enhancement, Self-esteem Enhancement, Family
Mobilization, and Support System Enhancement
(Halter 491)
Most important establishing a therapeutic relationship with the patient and asking directly about suicidal
feelings
Listening for the emotional feeling message underlying the verbal message, especially when the patient
presents as angry, hostile, and overwhelmed.
(Halter 486)

Determine the degree of severity:


(1) Is there a specific plan with details? (2) How lethal is the proposed method? (3) Is there
access to the planned method? People who have definite plans for the time, place, and means are at high
risk.
(Halter 486)
3 Levels of Interventions:
Primary-includes activities that provide support, information, and education to prevent suicide (Halter 487)
-Screen for risk factors and warning signs in adults and children in community centers, schools, homes,
hospitals and churches.
-Educate the community about suicide and how to recognize a mental health emergency.
Secondary-actual suicide crisis treatment.
-Counsel patient. Counseling skills, including interviewing, crisis care, and problem-solving techniques, are
used in both inpatient and outpatient settings.
(Halter 491)
-Advise to call suicide hotline.
-Health teaching and health promotion. Teach patient about diagnosis, meds, and therapy
-Help regain full control of meds.
Tertiary- postvention) refers to interventions with the circle of survivors of a person who has completed suicide
(Halter 491)
-Speak to family and friends about the situation.

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:

BOX 7-2 THE HEADSSS PSYCHOSOCIAL INTERVIEW


TECHNIQUE
H Home environment (e.g., relations with parents and siblings)
E Education and employment (e.g., school performance)
A Activities (e.g., sports participation, after-school activities, peer relations)
D Drug, alcohol, or tobacco use
S Sexuality (e.g., whether the patient is sexually active, practices safe sex, or uses
contraception)
S Suicide risk or symptoms of depression or other mental disorder
S Savagery (e.g., violence or abuse in home environment or in neighborhood)
(Halter 118)
Children: Developmental levels should be considered in the evaluation of children.
One of the hallmarks of psychiatric disorders in children is the tendency to regress
(i.e., return to a previous level of development). Although it is developmentally
appropriate for toddlers to suck their thumbs, such a gesture is unusual in an older
child. (Halter 118)
Adolescents: Adolescents are especially concerned with confidentiality and may
fear that anything they say to the nurse will be repeated to their parents. Lack of
confidentiality can become a barrier of care with this population. Adolescents need

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)

6. Nursing assessment in a crisis-types of crisis


Assessment
a. General assessment
b. Assessment of perception of precipitating event what was happening before this
c. Assessment of situational supports family, church, group,-is it positive
d. Assessment of personal coping skills -how is that working for you?
e. Self assessment

Diagnosis (Table 25-2)


o Ineffective coping
Outcomes identification (Table 25-3)
Implementation
f. Basic level
i. Patient safety
ii. Anxiety reduction

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.

8. Psychosocial Nursing process: Assessment, Diagnosis, Outcome planning, Implementation and


Evaluation
-The nursing process is a six-step problem-solving approach intended to facilitate and identify
appropriate, safe, culturally competent, developmentally relevant, and quality care for individuals,
families, groups, or communities
(Halter 115)
Assessment- Age considerations, language barriers, psychiatric mental health nursing assessment,
gathering date (review symptoms), spiritual/religious assessment, cultural and social assessment. (Halter
122)
Diagnosis- Identify nursing problems. A nursing diagnosis is a clinical judgment about a patients
response, needs, actual and potential psychiatric disorders, mental health problems, and potential comorbid
physical illnesses.
(Halter 123)
Outcomes-reflect desired change. Take into consideration culture, values, and ethical beliefs(Halter 123)
Planning: safe, compatible and appropriate, realistic and individualized, and Evidence based.
Implementation- See below in chart.
Evaluation- most neglected of the steps in nursing process.

9. The role of the nurse in supporting a patient with medication compliance


-Instruct the clients parents to administer this medication as prescribed on a daily basis to establish
therapeutic plasma levels.
-Assist with the clients medication regimen adherence by informing the client and parents that it may
take 1-3 weeks to experience therapeutic effects. Full therapeutic effects may take 2-3 months.
-Instruct the client and parents on the importance of continuing therapy after improvement in
manifestations. Sudden discontinuation of the mediation can result in relapse.
-Give only a 1 week supply of mediation for a client who is acutely ill, and then only give a 1-month
supply of medication at a time.
(ATI p 232)
-Risperidone also is available as a depot injection administered IM once every 2 weeks. This method of
administration is a good option for clients who have difficulty adhering to a medication schedule.
Therapeutic effect occurs 4-6 weeks after first depot injection.

-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.

12. Medications for treating anxiety


13.

Defense mechanisms

14. Identifying Obsessive Compulsive behaviors

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

Other compulsive disorders

15. Components of culturally competent care (more info needed at bottom)


So far, this chapter has explained why the nursing needs of culturally diverse patient populations are so varied.
Mental health and illness are biological, psychological, social, spiritual and cultural processes. Cultural
competence is required of nurses if they are to assist patients in achieving mental health and well-being. How,
exactly, are psychiatric mental health nurses to practice culturally competent care? The remainder of this
chapter suggests techniques that answer this question.
The USDHHS Office of Minority Health (2007) defines culturally competent care as attitudes and behaviors
that enable a nurse to work effectively within the patients cultural context. Cultural and linguistic competence
is a set of congruent behaviors, attitudes, and policies that come together in a system, agency, or among
professionals and enable effective work in cross-cultural situations. Cultural competence means that nurses
adjust their practices to meet their patients cultural beliefs, practices, needs, and preferences. Having cultural
sensitivity or awareness is an essential component of cultural competence. Culturally competent care goes
beyond culturally sensitive care by adapting care to the patients cultural needs and preferences (Narayan,
2006).
Campinha-Bacote (2008) recommends a blueprint for psychiatric mental health nurses in providing culturally
effective care: the Process of Cultural Competence in the Delivery of Healthcare Services. In this model, nurses
view themselves as becoming culturally competent rather than being culturally competent. This model suggests
that nurses should constantly see themselves as learners throughout their careersalways open to, and learning
from, the immense cultural diversity they will see among their patients. The model consists of five constructs
that promote the process and journey of cultural competence:
1.

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??

18. Documentation of care


The purposes of the medical record are to provide accurate and complete information about the care and
treatment of patients and to give health care personnel a means of communicating with one another, allowing
continuity of care. A records usefulness is determined by how accurately and completely it portrays the
patients behavioral status at the time it was written. The patient has the right to see the medical record, but it
belongs to the institution. The patient must follow appropriate protocol to view his or her records.
For example, if a psychiatric patient describes intent to harm himself or another person and his or her nurse fails
to document the informationincluding the need to protect the patient or the identified victimthe information
will be lost when the nurse leaves work. If the patients plan is carried out, the harm caused could be linked
directly to the nurses failure to communicate the patients intent. Even though documentation takes time away
from patient care, its importance in communicating and preserving the nurses assessment and memory cannot
be overemphasized.(Halter 111)

19. Therapeutic and non-therapeutic communication techniques


Therapeutic

Non therapeutic

20. Actions of the various neurotransmitters

21. Neuroimaging tests that are helpful in psychiatry