Post on 14-Jun-2018
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MENTAL HEALTH EXAM I STUDY GUIDE
Define and describe:
Voluntary /involuntary admission criteria/ who is eligible to be hospitalized without the
person’s consent?
Voluntary Admission: when a patient applies in writing for admission to the facility. If under 18
need a legal guardian. The PCP can reevaluate the patient and if the patient doesn’t want to
stay an involuntary admission may be required.
Involuntary Admission: In Maine patient needs to be “blue papered” to be hospitalized
involuntarily. Usually because patient is danger to themselves or others. Patient has rights to
retain freedom from unreasonable bodily restraints, right to informed consent, right to legal
counsel and the right to refuse medication. Can
Milieu=safe environment
Criteria for inpatient hospitalization
Most restrictive. Need referral by PCP or psychiatrist. Most patients admitted through
ER. Need one or more of the following to be admitted:
1. Imminent danger of harming self
2. Imminent danger of harming others
3. Unable to care for basic needs and/or gross impairment of judgment, placing an
individual at imminent risk based on inability to protect oneself.
Outpatient setting/ what does the care consist of here?
Community setting.
Tries to enhance patient strengths in the daily environment.
Uses support systems to learn how to cope with illness or difficult situations.
Intermittent supervision
Independent living environment w/ self-care and safety risks
Establish long-term relationship
Encourage med regiment.
Teach/support nutrition and self-care w/ referrals as needed.
Communicate regularly w/ support system (family) to assess and improve level of functioning
Develop comprehensive plan of care w/ attention to sociocultural needs and maintenance of
community living.
Partial hospitalization/what does the care consist of here?
Offer intensive short-term tx.
Patient can return home each day
5-6hrs/day w/individual and group psychotherapy
GOALS: improve symptoms, safety, education on illness & meds, coping strategies.
Inpatient hospitalization /what does the care consist of here?
24-hour supervision
Therapeutic milieu w/hospital supported healing environment.
Stabilization of symptoms and return to community.
Develop short-term relationship
Develop comprehensive plan of care w/ attention to sociocultural needs of pt and focus on
reintegration to the community
Administer meds
Monitor nutrition and self-care w/assistance as needed.
Provide health assessment and intervention as needed
Offer structured socialization activities
Plan for discharge w/family w/regard to housing and follow-up tx.
Recovery programs / what are they/ who do they treat? /for example, addiction, eating
disorder programs
Substance Abuse (drugs/alcohol)
Detoxification—when people quit the substance they are addicted to and go through
withdrawal. 24hr medical coverage while the patient clears out the drug from their body.
Rehab—medically monitored and has 24hr staff that provides care for those w/
biomedical or psych comorbid (multiple conditions in one illness) conditions. Patients can stay
long or short-term. Staff evaluates individuals and treats them, aiding in recovery and
improving function that possibly never developed while the patient was addicted.
Halfway House—A substance-free residential place for addicts to go. They work and go
to treatment programs (AA, NA etc). Focus is to extend sobriety, get assistance with education,
working social and economic needs.
Anorexia/Bulimia Nervosa/Binge-Eating Disorder
Acute Care—patient’s w/anorexia are admitted to an inpatient psych facility.
Long-term treatment possibly including: hospital stays, outpatient psychotherapy, and
meds.
Case management, case manager in mental health, what is their role, how do they help
persons with mental illness?
Case Management: helps the patient in the community with their mental illness, physical
health, spiritual health, education, social services and finding employment. The nurse helps the
patient and the patient’s support team with the patient’s treatment and living in the
community.
Summary of client rights /what document is this?
HIPPA (health insurance portability and Accountability Act)—privacy and confidentiality.
Right to be:
Treated w/ dignity
Involved in tx plan and decisions
Able to leave the hospital against medical advice.
Protected against harming themselves or others
Evaluated in a timely manner
Able to refuse tx and/or medications
Able to have legal counsel
Able to vote
Able to communicate privately with a person(s) or on the phone
Able to have informed consent
Able to have confidentiality protected with disorder or tx.
Able to have or not have visitors
Informed of research and refuse to participate
Able to have the least restrictive tx for their illness.
Able to send/receive mail.
Able to keep personal belongings unless its dangerous
Able to write a complaint following publicized procedure
Able to practice their religion.
What are the Laws that govern confidentiality: when is it ok to break confidentiality?
Confidentiality-the ethical responsibility of a health care professional that prohibits the
disclosure of privileged information w/o the patient’s informed consent. Can only be waived by
the patient, except if it’s to protect the patient, other persons or the public health, this is called
Duty to Warn.
Tarasoff law (duty to warn) - when patient intends to harm or kill another, health care
persons have a duty to warn that person. Tarasoff Law was a case in which a psychologist told
the police verbally and in writing that a student was going to kill another person. The police
questioned the student and cleared him. He ended up killing the person intended two months
later. This law created a duty to warn the person that is the target of the murder. It also created
the duty to protect in which the therapist they must call and warn the intended victim/victims
family/ or the police.
Tort-what is a tort? Be prepared to give an example of this (civil wrongdoing in practice)
Tort: a civil wrong for which money damages or other relief may be obtained by the injured
part from the wrongdoer.
Ex: healthcare professional overusing restraints (intentional tort), not getting patient consent.
Threats. Assault. Confinement.
Unintentional Torts—a tort that’s unintentional but still causes harm to the patient. Ex:
negligence.
What is the definition of ‘anosognosia’? (In relationship to a person with a severe/ serious
mental illness)
Anosognosia—patient’s inability to realize that they are ill due to the illness itself. Ex:
schizophrenic patients.
Therapeutic relationship and characteristics of in the nurse patient relationship
Therapeutic Relationship—when the nurse uses their skills to enhance patient’s growth.
Patient’s become more open and interact more when they realize the nurse respect their
concerns.
Characteristics:
Relying on a true understanding of what the client is telling the nurse
Relying on the verbal and nonverbal meaning conveyed by the client
Always mirroring back the understanding what the patient has told the nurse and verify
it with the patient.
Trust
Compassion
Empathy
Aware of the nurses own thoughts.
Observing, suspending judgement and negativity
Confidentiality
Manners
Respect
Use of space, silence, reflection, and offering one’s expertise and care to the patient
Boundaries in nurse/patient/family relationship/ what are they
Physical—general environment, office space, tx room, conference room. Area where patient
and nurse meet.
The Contract—confidentiality b/w nurse and patient.
Personal Space—physical and emotional space set by people involved.
Blurring of Boundaries—establish clear boundaries b/w nurse and patient.
Ex: patient becomes dependent on certain nurse, unwilling to do certain tasks without
certain nurse being there. (over-involvement)
Ex: Patient and nurse lack common goal, lack of progress towards goal, nurse doesn’t
follow-up w/patient. (under involved).
Respect /privacy- how does one demonstrate this with patients?
Respect the patient’s privacy and give respect to the patient.
SSDI (disability income) - what is it, why would persons with chronic mental illness get this.
Social security for the disabled.
SSDI- tax funded federal insurance program of US government for disabled, mentally or
physically.
Wellstone-Domenici Parity Act 2003—use of deductibles, copayments, coinsurance, tx
limitations, and out of pocket expenses. Affordable Care Act 2010-- Provides coverage for
uninsured w/ Medicaid eligibility. Created health insurance exchange in states, and insurance
mandate that people w/o coverage can obtain.
Theories of mental health care, evidence- based, Hildegard Peplau, Freud; id, ego, superego),
(nursing)
Hildegard Peplau— defined the therapeutic nurse-pt relationship as the foundation of the
nursing process.
Phases of Nurse-Patient Relationship:
Orientation—sizes up the situation, may ask for supervision/guidance, support from the
team or colleague when first meeting the patient. Establish rapport, nurse-pt relationship,
formal/informal contract, initial assessment, confidentiality, and terms of termination.
Working—maintain relationship, gather information, encourage pt’s problem-solving
skills, self-esteem and language skills. Behavioral change, work on goals, encourage the practice
of different behaviors.
Termination—summarize goals, incorporate new coping strategies, review situations of
relationship and exchange memories. Most therapeutic stage.
Freud—
ID: source of all drives (instinct, drive, genetics)
EGO: the problem solver and reality tester. (subjective/objective, memory images)
SUPEREGO: moral component, conscience, seeks perfection.
EGO DEFENSE MECHANISMS: unconscious management of anxiety to protect ego. Can
be adaptive or maladaptive (problematic).
DENIAL: failure ot acknowledge intolerable though, feeling, experience or reality.
Ex: alcoholic who says they don’t have a drinking problem.
DISPLACEMENT—redirection of emotions or feelings to a subject that is more
acceptable or less threatening. Ex: yelling at the dog when angry at the boss.
PROJECTION—attribution to others one’s unacceptable feelings, impulses
thoughts or wishes. Ex: saying someone you are angry w/ is angry with and dislikes you.
UNDOING—attempt to erase an unacceptable act, thought, feeling or desire. EX:
Apologizing excessively, OCD
COMPENSATION—an attempt to overcome a real or imagined shortcoming. Ex:
smaller in stature person excelling in sports.
SYMBOLIZATION— a less threatening object or idea is used to represent another
ex: dreams, phobias
SUBSTITUTION—replacing desired, impractical or unobtainable object w/ one
that’s acceptable or attainable. Ex: marrying someone who looks like a previous S.O.
INTROJECTION—occurs when a person internalizes ideas or voices of other
people commonly assoc. w/ the internalization of external authority, particularly of parents.
REPRESSION—unacceptable thoughts kept from awareness, inability to
remember a traumatic event, seen in PTSD patients.
REGRESSION--Return to an earlier developmental phase in the face of stress-
bedwetting, baby talk are examples.
DISASSOCIATION—detachment of painful, emotional experience form
consciousness. Ex: sleepwalking, no memory of an event
SUPPRESSION—consciously putting a disturbing thought/incident out of
awareness. Ex: deciding not to deal w/something unpleasant until the next day.
SUBLIMATION—substituting constructive activity for strong impulses that are
not acceptable.
REACTION FORMATION—expressing attitude directly opposite to unconscious
wish or fear-being excessively kind to a person who is disliked.
ERICKSON:
TRUST V MISTRUST—0-1.5yrs, forming attachment to individuals.
AUTONOMY V SHAME/DOUBT—1.5-3yrs, gaining control over self and environment
(toilet training, exploring)
INITIATIVE V GUILT—3-6yrs, becoming purposeful and directive
INDUSTRY V INFERIORITY—6-12yrs, developing social, physical and school skills
INDENTITY V ROLE CONFUSION—12-20yrs, making transition from childhood to
adulthood, sense of identity
INTIMACY V ISOLATION—20-35yrs, establishing intimate bonds of love and friendship
GENERATIVITY V SELF-ABSORPTION—35-65yrs, fulfilling life goals that involve family,
career, and society. Embrace future generations.
INTEGRITY V DESPAIR—65 to death, looking back over one’s life and accepting the
meaning of life.
Use of the Nursing process –determining priority interventions in mental health nursing, i.e.,
in the plan of care what gets to be the priority intervention (think of Maslow’s hierarchy of
needs here)
Nursing process:
Assessment—age of patient (child, adult, adolescent etc), mental status exam (MSE),
psychological assessment
Diagnosis—medical assessment, DSM IV, problem identification, identify goals, need to
be measurable, timed and attainable.
Plan—effective and client-centered. Safety, standard and compatible w/goals. Realistic
and based on evidence based practice (EBP)
Implement—coordinate tx, education, milieu, medications, safety!.
Evaluation—response to tx plan. DOCUMENT: SOAP notes, narrative notes.
Primary, secondary, tertiary care in mental health nursing community care setting
Primary—occurs before any problem occurs. Reduces incidences.
Secondary—aimed at decreasing the number of new and old cases of psych disorders.
Finds ways to detect illnesses early, and works on preventing them.
Tertiary—treatment and rehabilitation of the disease
Role of the mental health nurse in community care, what makes that nurse unique?
The nurse provides emergency services, adult services, child services, medication
administration, individual therapy, psychoeducational therapy, therapy groups, family therapy,
dual-diagnosis, psychosocial therapy (program that offers a structures day program, vocation
services and residential services), and psychiatric case management (service to help pts find
housing or entitlements.) Community health centers can provide long-term care for patients as
well.
Autonomy of the community nurse
Autonomy—respect patient’s rights to make their own decisions and respecting the patient’s
right to refuse medications.
How to: Support the client’s autonomy in community health nursing and other health care
settings
Serious mental illness: homelessness, jail, chronic illnesses
Co-morbidity: what are some of the more common chronic illnesses and why
Comorbid: multiple conditions at a time. Addiction and metabolic disease are comorbid
disorders. Types: schizophrenia, bipolar disorder and major depression.
Treatment modalities: For example, 1:1 psychotherapy, group therapy, names of group
therapy available, what nurses can conduct for therapy in mental health
Interpersonal Psychotherapy: short-term therapy that reduces symptoms by improving
social relationships.
Group Psychotherapy—leaders help a group of patients with psychiatric disorders.
CLASS #2 AND #3
Evidenced Based Care, Biology, Physiology, and Pharmacology
Maslow hierarchy of needs theory
Physiological—food, water, oxygen
Safety—security, protection, structure
Love and belonging—affiliation, affectionate relationships, love
Esteem—r/t competency, achievement, and esteem from others,
Self-actualization—becoming everything one is capable of
Self-transcendence
Nursing process in working with client with mental illness
Assessment: data gathered, subjective, objective
Diagnosis: using nursing diagnosis
Planning: setting goals with the patient, prioritizing care (always need to consider safety, i.e., is
patient suicidal? Or a danger to self or to others?)
Intervention / implementation: nursing interventions, prioritizing care (including administration
of medications)
Evaluation: Determining if goals were met
For bio-physiology and pharmacology:
Functions of the brain; function of each of the structural parts of the brain, different lobes of
the brain
Parasympathetic=rest and digest. Normal regulation of organs and systems
Sympathetic= fight or flight.
Circadian Rhythm=sleep regulated by various regions of the brain
Controls biological drives and behaviors, maintains homeostasis
Regulates autonomic nervous system and hormones
Memories, consciousness, fantasies, problem-solving, interpretation of the world, social
activities are also brain functions.
FOREBRAIN:
Cerebrum: cortex, largest part of the brain. Nerve cells make up the gray surface,
white nerve fibers carry signal b/w the nerve cells and the brain/body. Neocortex is bulk
of the cerebrum. Has 4 sections:
1. Frontal—reason, planning, speech, movement, emotion, and problem
solving
2. Parietal—sensory and motor, movement, orientation, recognition,
perception of stimuli
3. Occipital—visual processing, image recognition
4. Temporal—hearing, memory and speech
Thalamus: major relay station, monitors incoming info and then sends it to
upper regions of the brain.
Hypothalamus: (limbic system=emotional brain). Links to the pituitary gland,
regulates body temp, water, electrolytes, blood flow, sleep-wake cycle and levels of
hormones.
Amygdala: influences behavior and activities directed to the body needs,
concerned w/ emotion, drives (hunger, thirst, sex).
Hippocampus: grey matter that recognizes new experiences, learning and short
term memory.
MIDBRAIN: tectum and tegmentum. Brain stem, responsible for visual, auditory and
balance reflexes. Found underneath the limbic system. Used for basic vital functions (breathing,
heartbeat, blood pressure.
HINDBRAIN: cerebellum, pons and medulla.
Cerebellum—little brain. Two hemispheres, highly folded surface or cortex.
Assoc. w/regulation of movement, posture and balance.
Neurotransmitters, names, types, common in bio-physiology
Norepinephrine—deficiency causes depression. Affects receptors alpha 1 &2 and beta
1&2. Insufficient release of the neurotrans. by the presynaptic cell.
Serotonin—deficiency causes depression, anxiety and possibly suicide. EX: attaches to 5-
HT, 5-HT2, 5-HT3, 5-HT4. Influences hunger, mood, pain perception. Insufficient release of the
neurotrans. by the presynaptic cell.
Dopamine—excess causes schizophrenia. Affects receptors D1-D5.
Glutamate—direct influence on dopamine, creating a high risk for psychosis. NMDA and
AMPA receptor sites.
Y-amino butyric Acid (GABA)—excitability and anxiety. Increase GABA produces
soothing sense and sedation. GABA A and GABA B
Acetylcholine—released by parasympathetic NS, attaches to muscarinic receptors on
internal organs. Cholinergic, muscarinic receptors
Diagnostic brain procedures, for example, PET
EEG—electrical recording of signals in the brain. Electrodes are placed externally on
head. Show activity of brain while asleep and awake. Activity differs with each state.
CT/CAT Scan—computerized axial tomography, series of x-ray images taken, computer
analysis show 3d slices of segment. Can detect: lesions, abrasions, aneurysms, and infarct.
MRI—magnetic resonance imaging. Uses nuclei of hydrogen atoms that absorb and
remit radio waves. Shows 3d image of brain. Detects: brain edema, ischemia, infection,
neoplasm and trauma.
Functional MRI—measures brain activity by detecting changes in blood oxygen levels in
different parts of the brain. Person participates in different activities while the test is
conducted. (pts w/ OCD show brain metabolism increase in areas of frontal cortex).
(Schizophrenic pts show reduced frontal lobe brain activity)
PET— photon emission computed tomography, detects: oxygen, glucose, blood flow
and neurotrans. receptor interaction. (Pts w/ depression shows decreased activity in prefrontal
cortex).
SPEC—single photon emission computed tomography—uses radionuclides that emit y-
radiation, measure aspects of brain functioning and provides images of CNS. Detects:
circulation of CSF (cerebrospinal fluid).
Categories of psychiatric medications and the neurotransmitters they target, or enhance
1. Antidepressants-
a. Tricyclic- block muscarinic receptors, block reuptake of norepinephrine and
serotonin.
i. Nortriptyline
ii. Amitriptyline
iii. Imipramine
iv. Side effects:
1. Dry mouth
2. Blurred vision
3. Tachycardia
4. Urinary retention
5. Constipation
b. SSRIs (Selective-Serotonin Reuptake inhibitor), SNRIs (serotonin-
norepinephrine Reuptake inhibitor), NDRIs (norepinephrine- Dopamine
inhibitor)
i. Fluoxetine--SSRI
ii. Paroxetine--SSRI
iii. Citalopram--SSRI
iv. Fluvoxamine—SSRI
v. Setraline--SSRI
vi. Bupropion—NRDI
vii. Duloxetine—SNRI
viii. Venlafaxine--SNRI
2. Mood stabilizers
a. Regulates moods
b. Tx bipolar I and II
c. Lithium Carbonate —mimics sodium causing fluid/electrolyte imbalance. Need
frequent blood tests.
d. therapeutic level 0.5 to 1.5 lithium toxicity
Anticonvulsants: used as mood stabilizers
e. Valproate Acid (Depakote)—causes weight gain
f. Carbamazepine (Tegretol)
g. Lamotrigine (Lamictal)—used a lot, but can cause johnson’s stevens syndrome
(deadly rash)
h. Gabapentin (Neurontin)—chronic pain tx
i. Topiramate (Topamax)--
j. Oxcarbazepine ( Trileptal)
3. Antipsychotics
a. Schizophrenia and psychosis are r/t excess dopamine
b. First generation:
i. Antagonists of the D2 receptors of dopamine.
ii. Major problems of movement and motor activity.
iii. Chlorpromazine
iv. Haloperidol
v. Fluphenazine.
c. Second Generation:
i. Less side effects than first generation
ii. Increase in risk for metabolic syndrome
iii. *Weight gain
iv. *Increase in blood glucose level
v. *Increase in triglycerides
vi. Clozapine (Clozaril)—drooling side effect, WBCs, frequent blood draws.
vii. Risperidone (Risperdal)
viii. Olanzapine (Zyprexa)
ix. Ziprasidone (Geodon)**can cause changes in cardiac rhythm. Need
baseline EKG
x. Quetiapine (Seroquel)--sedation
d. Third Generation:
i. Dopamine system stabilizer
ii. Unique antipsychotic
iii. Partial agonist of dopamine .
iv. In areas of brain where there is excess dopamine, medication lowers the
level
v. Where dopamine is needed , it stimulates the receptors to raise the
dopamine level
vi. Aripiprazole (Abilify)
4. Anti- anxiety medications ( benzodiazepine and other anxiolytics)
a. Involved is the neurotransmitter GABA
b. GABA modulates neuron excitability and anxiety
c. increase the GABA neurotransmitter
d. Highly addictive—no alcohol, monitor renewal rate.
e. Benzodiazepines cause CNS depression and are also highly addictive
f. Diazepam (Valium)-intermediate acting
g. Clonazepam (Klonopin)-long acting , slow onset
h. Alprazolam (Xanax)-short acting, quick response
i. Lorazepam (Ativan)-short acting
j. NON addictive:
i. Buspirone (Buspar)
ii. Gabapentin (Neurontin)
iii. Some antidepressants- Paroxetine (SSRI)
5. Anticholinergics
a. Used to treat side effects from the blocking of the muscarinic receptors that
occur with antipsychotics.
b. Will review when discussing schizophrenia, psychosis
Nursing considerations for each class of medications, i.e., what to consider when
administering; for example, MAOI require a particular diet (avoid foods with tyramine) when
taking or there can be a hypertensive crisis.
Monoamine oxidase inhibitors—avoid foods w/ tyramine such as aged cheese, red
wine, hot dogs, and salami. Examples of MAOIs: phenelzine, tranylcypromine.
CLASS #4
Communication as centerpiece of nursing care and the therapeutic relationship
1. Transference , Countertransference
a. Transference—when the pt unconsciously and inappropriately displaces onto
the nurse feelings/behavior r/t significant figures in the pt’s past. Ex: you remind
me of my mother.
b. Countertransference—when the nurse unconsciously and inappropriately
displaces onto the pt feelings/behavior r/t to significant figures in the nurse’s
past. Ex: Patient decides not to go to AA. Nurse says “you always sabotage your
chances. You need AA to get in control of your life….Now you’ve disappointed
everyone”.
2. Verbal:
The types and examples of communication that are effective, non-effective
Acceptance—encouraging and receiving information in a nonjudgmental manner
Interpretation—put into words what the patient is implying/feeling
Restatement—repeating the main idea expressed letting the pt know what was
heard.
Reflecting—redirecting the idea back to the pt for classification of emotional
overtones, feelings and experiences.
Exploring—introducing and idea and letting the pt respond
Confrontation—presenting the pt w/a different reality of the situation
Doubt—expressing or voicing doubt when a pt releases a situation
Validation—clarifying the nurse’s understanding of the situation.
Silence—remaining quiet but still interested
Observation—stating to the pt what the nurse is observing
Responding with Empathy vs Sympathy
Empathy—ability to understand what a pt is going through. You can relate
Sympathy—you feel sorry for the person, but cannot relate to it.
3. Nonverbal communication:
a. Excess questioning
b. Approval/disapproval
c. Giving advice
d. “why?”
e. Eye contact
f. Bias/Prejudice/culture filters
CLASS #4 (continued)
STRESS AND CRISIS THEORY
Definition of stress—based on person’s psych perceptions; threat, vulnerability, and ability to
cope.
Distress: when the stress exceeds coping skills
Eustress: good stress, helpful and fulfilling stress.
Responses to stress
Serotonin---more active, may impair serotonin receptor sites and brains ability to use
serotonin.
Immune Response—NS and immune system interact during alarm phase of General
Adaptation Syndrome (three stages: alarm/acute, resistance/adaptation, and exhaustion).
Negative affects production of protective factors (people get sick).
Mediators—stressors: physical and psychological. Perception, individual temperament.
Social support: groups, cultures, religion/spirituality.
Definition of crisis—sudden event that disturbs homeostasis. Usual coping mechanisms do not
work. Lasts 6-8 weeks, acute and limited timing.
Theory of crisis
Aguilera, Mesnick, Roberts—crisis theorists.
Types of crisis
1. Developmental/maturational—Follows Erickson’s stages, a developmental or growth
issues that brings physical, cognitive, sexual, and instinctual changes.
2. Situational—Unanticipated, extraordinary or external event. Threatens self-concept and
self-esteem. Ex: loss of job, death of loved one, unwanted pregnancy, loss of money, loss
of home, physical illness, mental illness.
3. Adventitious—Unexplained or accidental event. Natural disaster, national disaster, crime,
violence. Ex: flood, fire, terrorism, war, riots, abuse, 9/11, Orland club shooting, Boston
bombings, tornadoes in New Orleans. In adventitious crisis there may also be a critical
incident debriefing following the crisis incident.
Phases of crisis
1. Conflict/problem, self-concept is threatened, increasing anxiety. Person tries to
solve/address problem w/usual coping skills. Uses defense mechanisms as way
of coping. Problem may be resolved decreasing anxiety.
2. If defense mechanisms fail, threat persists, anxiety still increases, extreme
discomfort, disorganized, trial-and-error attempt to solve problem.
3. When trial-and-error fails. Anxiety is now panic. Automatic relief behaviors
mobilized (fight/flight). Resolution may be devised (compromise, redefine
situation).
4. Problem is unsolved still. Coping skills are not working and pt is still panicking,
can cause depression, violence against others, and suicidal behavior.
Use of the nursing process in crisis
Assessment—perception of event, coping skills, situational support. G.ather data, other
persons perception of event, other coping skills, your thoughts and feelings
Diagnosis—risk for injury to self or others. Impairment to solve problems. Ineffective
coping. Unable to use defense mechanisms, impaired communication.
Plan—6-8 weeks plan. Realistic, SAFETY, SAFETY, SAFETY from injury to others,
violence, homicide.
Implement
Primary—therapeutic relationship, creating external controls for protection. Use
effective communication skills, identify safety skills. Promote mental health to prevent future
crisis.
Secondary—prevention of prolonged anxiety, diminished effectiveness in
meeting needs, may need inpatient care if unsafe.
Tertiary—support for those who have had a severe crisis and now in disabled
state. Tx found in outpatient clinics, partial hospital, shelter, and rehab centers
Evaluate—patient has less anxiety in 6-8 weeks. Person can now function and has
balance again. Possible growth and change in persons life.
Assessment of physiological and psychological symptoms
Injury, anxiety, depression, suicide.
Definition of Levels of care: Least restrictive to most restrictive.
1. Psychiatric services: out-pt clinics
2. Case management
3. Crisis intervention
4. Crisis beds
5. Emergency services
--Least= primary care provider, specialist, partial hospital.
--Most=Inpatient care.
Examples of questions to expect: whether the question is a knowledge, analysis,
comprehension, or application
1. A nurse cares for four patients who are receiving clozapine, lithium, fluoxetine, and
venlafaxine, respectively. With which patient should the nurse be most alert for
problems associated with WBC decrease? The patient receiving:
Multiple choice
What medication will you decide on?
CLOZAPINE
Knowledge and application question
2. The nurse conducts an initial crisis intervention interview of a person. . The priority
assessment the nurse must make during this initial crisis intervention interview is:
Multiple choice
What assessment is a priority when first assessing a person in crisis?
Perception of precipitating event, situational supports and personal coping skills
Knowledge question
3. The patients below present to the emergency department. The psychiatric unit has
one bed available. Which patient would the nurse expect to be admitted? The
patient:
Multiple choice
Which patient will you expect to be admitted to a psychiatric inpatient unit?
The one that is trying to harm themselves, others, or cannot physically or mentally take
care of themselves.
Knowledge and application