PVN123 – Mental Health Nursing - Presentation #4

 Identify common medications used to treat mental disorders (ATI Tutorial 2011B)  Identify expected pharmacological actions  Identify therapeutic uses  Identify side/adverse effects  Identify contraindications and precautions  Identify food and medication interactions  Identify patient teaching strategies  Identify Traditional Non-pharmacological Therapies for the treatment of mental health disorders

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Click on the link below for a video message from your instructor.

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http://www.screencast.com/t/7 2WMOeLbNzP

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ATI Tutorial (Course Quiz #2)

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Pharmacology Made Easy 2.0

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ID = TU1532398

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Password = 15F7U

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Module = The Neurological System (Part 2)

Here’s a Link to the ATI Website!

https://www.atitesting.com

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Psychoanalysis / Psychotherapy / Behavioral Therapies Group and Family Therapy Stress Management Electroconvulsive Therapy

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Approaches to addressing mental health issues using various methods and theoretical bases

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Nurses should be familiar with methods employed!

 Assessing unconscious thoughts and feelings  Resolving conflict through talking to psychoanalyst  Many sessions over months to years  Not usually sole therapy of choice  Lengthy duration and insurance constraints  First developed by Sigmund Freud  Past relationships are common focus • • • • Therapeutic Tools Used: Free Association • Spontaneous/uncensored verbalization of whatever comes to mind Dream Analysis Transference • Feelings that client has developed toward therapist related to someone else from early childhood Use of defense mechanisms

 More verbal therapist/client interaction than traditional psychoanalysis  Trusting relationship between client and therapist  Includes:  Psychodynamic Psychotherapy  Interpersonal Psychotherapy (IPT)  Cognitive Therapy  Behavioral Therapy  Cognitive Behavioral Therapy

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Psychodynamic Psychotherapy

 Same tools as Psychoanalysis But!....

 Oriented more to client’s present state than early life

Interpersonal Psychotherapy (IPT)

 Used for clients with specific problems  Can improve interpersonal relationships / communication / role-relationship / bereavement

Cognitive Therapy

 Based on cognitive model – focuses on individual thoughts/ behaviors to solve current problems.

▪ Used to treat depression / anxiety / eating disorders / other issues that require changing attitude toward life experiences

Behavioral Therapy

 Focuses on changing behavior  Based on theory that behavior is learned and has consequences  Abnormal behavior is result of avoiding painful feelings  Teaches clients to decrease anxiety or avoidant behavior  Used successfully to treat phobias / addictions

Cognitive Behavioral Therapy

 Uses both cognitive and behavioral approach  Used in anxiety management

 Anxiety decreased by changing cognitive distortions 

Cognitive Reframing

 identify negative thoughts that produce anxiety ▪ Examine the cause ▪ Develop supportive ideas 

Priority Restructuring

▪ identifying priorities 

Journal Keeping

▪ writing down stressful thoughts 

Assertiveness Training

▪ expressing feelings and solving problems in nonaggressive manner 

Monitoring Thoughts

▪ becoming aware of negative thinking

Modeling Type

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Definition

Therapist serves as role model for client   

Use in MH Nursing

Improving interpersonal skills Therapist demonstrates behavior in stressful situation Goal is for client to imitate the behavior

Operant Conditioning Systematic Desensitization Aversion Therapy Medication / guided imagery/ diaphragmatic breathing / muscle relaxation / biofeedback

     Positive rewards for positive behavior Planned, progressive, or graduated exposure to anxiety provoking situations and stimuli o Real life situations or imagining events Anxiety response is suppressed through relaxation techniques Maladaptive behavior paired with a punishment or unpleasant stimuli      Techniques used to control pain / tension / anxiety   Ex: tokens given for good behavior which can be exchanged for a privilege or other items Client masters relaxation techniques Client exposed to increasing levels of anxiety producing stimulus Relaxation used to overcome anxiety Client then able to tolerate greater and greater level of stimulus Therapist uses unpleasant stimuli as punishment for undesirable behaviors o Bitter taste/mild electric shock Ex: Reinforced teaching about diaphragmatic breathing for client having a panic attack.

 Other techniques  Flooding ▪ Exposing (in presence of therapist) to a great deal of an undesirable stimulus ▪ Attempt to “turn off” anxiety response  Response Prevention ▪ Prevent client from performing compulsive behavior ▪ Intent is that anxiety will be diminished  Thought Stopping ▪ Teaching client to shout the word “STOP” when negative thoughts or compulsive behaviors arise ▪ Over time the client will use the command silently

 A client states that he is depressed because he has had to deal with role reversal with his spouse after the loss of his job due to a disability. Which of the following therapies would the nurse expect to help implement for the client?

    A. Operant conditioning B. Systematic desensitization Psychodynamic psychotherapy Interpersonal psychotherapy

Answer Psychoanalysis Cognitive Technique Assertiveness Training

A A client who has had heated disputes with other clients on the unit learns to solve problems by sitting down and talking calmly and reasonably with other clients.

B The client discusses his dreams with the therapist.

C The client is encouraged to stop sucking his thumb by having a bitter liquid applied to his thumb.

Aversion Therapy Modeling

D A client who feels awkward in group social situations watches a video showing some positive ways to interact in groups.

E A client who displayed violent behavior in the past and felt negative about herself, learns to think and speak about herself in more positive terms.

 Open therapeutic communication  Participants willing to be involved  Part of treatment plan for clients in mental health setting  Guided by leaders  Leadership styles include:  Democratic ▪ Supports group interaction and decision making to solve problems  Laissez-faire ▪ Group progresses with no attempt by the leader to control the direction of the group  Autocratic ▪ Leader completely controls the direction and structure of the group ▪ No group interaction or decision-making to solve problems

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Group Therapy Isn’t…

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http://www.youtube.com/watch?v=cEFAHOzc8no

 Verbal and nonverbal communication occurring within group sessions  Group Norm  The way the group behaves during sessions  Provides structure for the group  Hidden Agenda  Some group members (or leader) have goals different from the stated group goals ▪ May disrupt group progress  Subgroup  Small number of people within a larger group ▪ Function separately from the group  Groups may be open or closed  Open groups – new members added as old members leave  Closed groups – no new members added after the group is formed

 Homogenous group  All members share a certain characteristic ▪ Ex: diagnosis or gender  Therapy sessions include  Use of open and clear communication  Cohesiveness and guidelines  Direction toward a goal  Opportunity for development of: ▪ Interpersonal skills ▪ ▪ Resolution of personal / family issues Relationship development  Communication regarding respect among members  Support and education regarding community support resources

 Group Therapy Goals:  Sharing of common feelings / concerns  Sharing of stories / experiences  Diminishing feelings of isolation  Creating a community of healing and restoration  Providing more cost-effective environment than individual counseling  Group therapy may be used for varying age groups:  Children ▪ play while talking about a common experience  Adolescents ▪ Especially valuable due to strong peer relationships  Older Adult ▪ Helps with socialization and sharing memories

 Maintenance Roles  Members maintain the purpose and process of the group ▪ Ex: harmonizer ▪ Attempts to prevent conflict within the group  Task Roles  Members take on various tasks within the group process ▪ Ex: recorder ▪ Takes notes or records of what occurs  Individual Roles  Individuals take roles to promote their own agenda  Prevents teamwork  Ex: dominator ▪ Tries to control other members

  Family defined as a group with reciprocal relationships Members are committed to each other  Family Therapy  Focus is on the family as a system rather than members as individuals  Family assessments include focused interviews and use of various family assessment tools  Nurses work with families to: ▪ Provide teaching ▪ ▪ ▪ Mobilize family resources Improve communication Strengthen ability to cope with illness of one member

Area of Functioning Communication Management Boundaries Socialization

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Healthy Families

Clear understandable messages between family members Each member encouraged to express individual feelings and thoughts  

Dysfunctional Families

One or more members use unhealthy patterns o Blaming o Manipulating o Placating o Distracting Management may be chaotic o Child making management decisions at times Adults of family agree on important issues Rule-making Finances Plans for the future Distinguishable boundaries between family roles Clear boundaries defined for each member Boundaries understood by all Each member can function appropriately   Enmeshed boundaries o Thoughts/roles/feelings are so blended that individual roles are unclear Rigid boundaries o Rules and roles are inflexible o Family tends to have isolated members    All members interact / plan / adopt healthy ways of coping Children learn to function as family and society members Members can change as the family grows and matures   Children do not learn health socialization skills within the family Have difficulty adapting to socialization roles in society

Emotional/Supportive

   Emotional needs of family and members are met most of the time Members are concerned about each other Conflict and anger do not dominate   Negative emotions predominate most of the time Members are isolated and afraid o Do not show concern for each other

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Scapegoating

 A member of the family has little power  Blamed for problems in the family 

Triangulation

 Third party is drawn into the relationship with two members whose relationship is unstable 

Multigenerational Issues

 Emotional issues within the family that continue for at least three generations ▪ Addiction patterns when family under stress ▪ ▪ ▪ Dysfunctional grief patters Triangulation patterns Divorce

Therapy Individual Family Group

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Focus

Client needs and problems The therapeutic relationship  Family needs and problems Improving family relationships     Help individuals develop functional and satisfying relations within a group setting   

Goals

Make more positive individual decisions Make productive life decisions Develop a strong sense of self Learn effective ways for dealing with mental illness within the family Improve understanding among family members Maximize positive interaction among family members Goals depend on type of group Clients generally: o Discover that members share o common feelings / experiences / thoughts Experience positive behavior changes as result of group interaction and feedback

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Structural family therapy example

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http://www.youtube.com/watch?v=bOrnOcHWXgA

 A nurse leading a stress management group demonstrates that he supports group interaction and the decision-making required to solve problems. The group proceeds with all members feeling that they have input into the group’s decisions. Which leadership style does this illustrate?

    A. Democratic B. Laissez-faire C. Autocratic D. Authoritative

 A nurse is conducting a family therapy session. The teenage son tells the nurse that his parents will punish him harshly if he discloses anything in the session about the family’s arguments at home. The parents have never made any such threats to him. This is an example of which of the following?

    A. placation B. manipulation C. blaming D. distraction

 Body’s nonspecific response to any demand made upon it  Stressors  Physical  Psychological  Produces a biological response in the body  Some stressors are needed to provide interest and purpose  Too much stress or too many stressors can cause distress  Anxiety and anger are damaging stressors that cause distress  General Adaptation Syndrome (GAS)  Body’s response to an increased demand  First stage = “Fight or Flight” mechanism ▪ If prolonged, maladaptive responses may occur

 The person’s ability to experience appropriate emotions and cope with stress  Healthy management of stress  Flexible  Uses a variety of coping techniques and mechanisms  Responses to stress/anxiety affected by:  Age  Gender  Culture  Life experiences  Lifestyle  Effects of stressors are cumulative

 Things that increase ability to resist the effects of stress  Physical health  Strong sense of self  Religious/spiritual beliefs  Optimism  Hobbies and other outside interests  Satisfying interpersonal relationships  Strong social support systems  Humor

Acute Stress “Fight or Flight” Apprehension Prolonged Stress (maladaptive responses)

Chronic anxiety or panic attacks

Unhappiness / sorrow

Depression / chronic pain / sleep disturbances

Decreased appetite

Weight gain or loss

Increased respiratory rate / heart rate / cardiac output / BP Increased metabolism and glucose use

Increased risk for myocardial infarction / stroke Poor diabetes control / hypertension / fatigue / irritability / decreased ability to concentrate

Depressed immune system

Increased risk for infection

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Life-Changing Events Questionnaires

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Holmes Rahe Stress Scale (see handout)

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Lazarus’s Cognitive Appraisal

 Reinforce teaching of stress reduction strategies  Cognitive Retraining ▪ Help clients look at irrational thoughts in a more realistic light and restructure thoughts in a more positive way.

 Behavioral Techniques ▪ Relaxation techniques ▪ Meditation ▪ Guided imagery ▪ ▪ Breathing Exercises Progressive Music Relaxation (PMR) ▪ Physical Exercise • •

Client Outcomes

Client will verbalize stressors and ways to decrease exposure Client will demonstrate   Journal Writing Priority Restructuring appropriate relaxation techniques  Biofeedback •  Assertiveness Training Client will demonstrate assertive communication

Scenario: A client speaking to a nurse in a general medical clinic, describes herself as feeling anxious, apprehensive, and tired all the time. She says she cannot understand why, since she is very happy. She recently moved to the area to start a new job for a large corporation. She purchased a new and much larger home for herself and her three children (ages 5, 8, and 12). The children transitioned to their new schools successfully and are making friends. The client’s family and friends are all back in the previous city where she lived, but she has been so busy with work that she has not had time to telephone or write to them. The client states she has not been able to sleep and has lost weight in the 2 months since the move.

1. List the stressors that affect this client.

2. Which of the client’s manifestations of increased stress reflects acute Stress rather than prolonged stress?

a. Weight loss b. Apprehension c. Fatigue d. Insomnia

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Electroconvulsive Therapy

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http://www.youtube.com/watch?v=zYl13Relzbs

 Alternative somatic treatment for mental health disorders  Delivers an electrical current that produces a grand mal seizure  The exact mechanism of ECT is still unknown and controversial  May enhance the effects of neurotransmitters in the brain ▪ Serotonin ▪ Dopamine ▪ norepinephrine

 Severe depression  Symptoms not responsive to pharmacological treatment  If risks of other treatments outweigh those of ECT ▪ First trimester of pregnancy  Actively suicidal ▪ Need for rapid therapeutic response  Some types of Schizophrenia  If less responsive to neuroleptic medications ▪ Catatonic schizophrenia ▪ Schizoaffective disorder  Acute manic episodes  For bipolar clients with rapid cycling and very destructive behavior ▪ Four or more episodes of acute mania within 1 year ▪ Both features usually do not respond well to Lithium therapy

 No absolute contraindications if deemed necessary to save / improve a client’s life  Medical conditions for high risk with ECT  Recent myocardial infarction  History of cerebrovascular accident  Cerebrovascular malformation  Intracranial mass lesion  Medical conditions for which ECT is useful:  Developmental disabilities  Chemical dependence  Personality disorders  Situational depression

 Prepare the client  Typical course of treatment is 3 x /week for 6 – 12 treatments  Use therapeutic communication  Physician will discuss the procedure and obtain informed consent  Risks and benefits  Guardian gives consent if client incompetent  Sometimes separate informed consent for anesthesia  History and physical examination ▪ Neuro exam ▪ ▪ Electrocardiogram (ECG) Lab tests

 Medication management  Meds that affect client’s seizure threshold are decreased or discontinued several days before ECT procedure.

 MAOIs and lithium should be DC’d 2 weeks before the procedure  Severe hypertension is controlled  Short period of hypertension post procedure ▪ Monitor vital signs ▪ Monitor mental status  Ask client and family about understand and knowledge of the procedure  Redirect to MD for clarification as needed  IV inserted and maintained until full recovery  IM injection of atropine sulfate or glycopyrrolate (Robinul) is given 30 minutes prior to procedure to decrease secretions and counteract vagal stimulation.

        ECT administered in early morning  After 8 – 12 hours of fasting Client uses bite guard to prevent oral cavity trauma Electrodes are applied to the scalp The client is mechanically ventilated and receives 100% oxygen Ongoing cardiac monitoring provided  BP / heart rate and rhythm / oxygen saturation Short acting anesthetic (Brevital) is provided IV bolus Muscle relaxant (Anectine) is administered Cuff placed on one leg or arm  Blocks muscle relaxant so seizure activity can be monitored and documented  Duration of seizure is usually 25 to 60 seconds   After seizure activity is ceased, anesthetic is discontinued Client is extubated and assed to breathe voluntarily

 Client is transferred to recovery area  Assess: ▪ LOC ▪ Cardiac status ▪ Vital signs ▪ Oxygen saturation  Position client on side to facilitate drainage and prevent aspiration  Client is usually awake are ready for transfer back to the mental health unit within 30 to 60 minutes after the procedure  Orient client frequently  Confusion and short-term memory loss are common  Continue to monitor vital signs and mental status for memory loss

 Memory loss and confusion  Short term memory loss ▪ May persist for several weeks ▪ If ECT causes permanent memory loss is controversial  Confusion  Disorientation  Explain to clients and families that memory loss is typically short term  Assist client with memory ▪ Clock in the room ▪ Label client’s room location  Headache / muscle soreness / nausea  Observe degree of discomfort  Administer antiemetic and analgesic medication as needed  Explain the reason for clinical manifestations  Encourage clients to contact nurse regarding these symptoms

 Identified common medications used to treat mental disorders (ATI Tutorial 2011B)  Identified expected pharmacological actions  Identified therapeutic uses  Identified side/adverse effects  Identified contraindications and precautions  Identified food and medication interactions  Identified patient teaching strategies  Identified Traditional Non-pharmacological Therapies for the treatment of mental health disorders

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See Schedule for assignments due for next class

 ATI Tutorial (Quiz #2) due!

 Mid Term Evaluations  Q&A  Special Populations and Mental Health Issues  (Ppoint Presentation and Study Guide #5)  Nursing Process and Care Plan Development for Mental Health  ATI Practice Test #2  Be sure to practice before test!!

 Grade on practice will be averaged with your graded test