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Mental Health
● The WHO defines health as a state of complete physical, mental, and social
wellness, not merely the absence of disease or infirmity.
● Mental health is influenced by individual factors, including biologic makeup,
autonomy, and independence, self-esteem, capacity for growth, vitality, ability to
find meaning in life, resilience or hardiness, sense of belonging, reality
orientation, and coping or stress management abilities; by interpersonal factors,
including effective communication, helping others, intimacy, and maintaining a
balance of separateness and connectedness; and by social/cultural factors,
including sense of community, access to resources, intolerance of violence,
support of diversity among people, mastery of the environment, and a positive yet
realistic view of the world (damn, that was a mouthful!).
Mental Illness
● The APA (2000) defines a mental disorder as “a clinically significant behavioral
or psychological syndrome or pattern that occurs in an individual and that is
associated with present distress or disability or with a significantly increased risk
of suffering death, pain, disability, or an important loss of freedom”.
● Deviant behavior does not necessarily indicate a mental disorder.
Diagnostic and statistical manual of mental disorders
● The DSM-IV-TR is a taxonomy published by the APA. The DSM-IV-TR
describes all mental disorders, outlining specific criteria for each based on clinical
experience and research.
● The DSM-IV-TR has 3 purposes:
○ To provide standardized nomenclature and language for all mental health
professionals.
○ To present defining characteristics or symptoms that differentiates specific
diagnoses.
○ To assist in identifying the underlying causes of disorders.
● A multiaxial classification system that involves assessment on several axes, or
domains of information, allows the practitioner to identify all the factors that
relate to a persons condition.
○ Axis I is for identifying all major psychiatric disorders except MR and
personality disorders. Examples include depression and schizophrenia.
○ Axis II is for reporting mental retardation and personality disorders as well
as prominent maladaptive personality features and defense mechanisms.
○ Axis III is for reporting current medical conditions that are potentially
relevant to understanding or maintaining the person’s mental disorder as
well as medical conditions that might contribute to understanding the
person.
○ Axis IV is for reporting psychosocial and environmental problems that
may affect the diagnosis, treatment, and prognosis of mental disorders.
Included are problems with the primary support group, the social
environment, education, occupation, housing, economics, access to health
care, and the legal system.
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○ Axis V presents a Global Assessment of Functioning which rates the
person’s overall psychological functioning on a scale of 0 to 100. This
represents the clinician’s assessment of the person’s current level of
functioning.
● All clients admitted to a hospital or psychiatric treatment will have a multiaxis
diagnosis from the DSM-IV-TR.
Period of Enlightenment and Creation of Mental Institutions
● In the 1790’s Phillippe Pinel in France and Willian Tukes of England formulated
the concept of asylum as a safe refugee or haven offering protection at
institutions where people had been beaten, whipped, and starved for their mental
illness.
● In the US, Dorothea Dix (1802-1887) began a crusade to reform the treatment of
mental illness after a visit to the Tukes’ institution in England. She was
instrumental in opening 32 state hospitals that offered asylum to the suffering.
● 100 years after establishment of the first asylum, state hospitals were in trouble.
Attendants were accused of abusing the residents, the rural locations of the
hospitals were viewed as isolating patients from their families and homes, and the
phrase insane asylum took on a negative connotation.
Development of Psychopharmacology
● In the 1950’s the development of psychotropic drugs were used to treat mental
illness.
● Chlorpromazine (Thorzine), an antipsychotic drug, and lithium, an anti-manic
agent, were the first drugs to be developed.
● 10 years later, monoamine oxidase inhibitors, haloperidol (Haldol), an
antipsychotic; tricyclic antidepressants; and antianxiety agents (benzodiazepines),
were introduced.
● Because of these new drugs, hospital stays were shortened, and many people were
well enough to go home.
Move toward Community Mental Health
● The enactment of the Community Mental Health Centers Act came about in 1963.
● Deinstitutionalization, a deliberate shift from institutional care in state hospitals
to community facilities, began.
● In addition to deinstitutionalization, federal legislation was passed to provide an
income for disabled persons: SSI and SSDI. This allowed people with mental
illnesses to be more independent financially and not to rely on family for money.
Mental Illness in the 21st Century
● The Department of Health and Human Services (DHHS) estimates that 56 million
Americans have a diagnosable mental illness.
● The term Revolving door effect is used to explain how people with severe and
persistent mental illness have shorter hospital stays, but they are admitted more
frequently. People with severe and persistent mental illness may show signs of
improvement in a few days but are not stabilized. Thus, they are discharged into
the community without being able to cope with community living. Substance
abuse issues cannot be dealt with in the 3-5 days typical for admissions in the
current managed care environment.
● Many providers believe today’s clients are to be more aggressive than those in the
past. Between 4% and 8% in clients seem in Psychiatric ER’s are armed. People
Chapter Two
Neurobiologic Theories and Psychopharmacology
The Nervous system and how it works
Mood disorders
Categories of Mood disorders
● Unipolar
○ Major depression
● Bipolar
○ Mania
○ Depression
○ Period of normalcy
Unipolar: Major depression
● Sad mood or lack of interest in life for 2 or more weeks
● Another 4 symptoms must also be present
○ Change in appetite (increase or decrease)
○ Change in sleep patterns (too much or too little)
○ Unable to concentrate and make decisions
○ Loss of self-esteem (guilt- how you were raised; how worthy a person
perceives themselves).
● Those at risk:
○ PMS/PMDD
Incidence
● Major depression occurs at least twice as often in women
● Single and divorced people have the highest rates of depression
Treatments
● Psychotherapy (groups, counselor)
● Psychopharmacology (Meds)
● ECT
Electroconvulsive therapy
● The biggest concern is memory loss.
● Patient is pre-medicated, much like a pre-op patient
● Elders are treated for depression with ECT more frequently than younger persons.
○ Elder persons have increased intolerance of side effects of antidepressants
○ ECT produces a more rapid response
Suicidal Ideation
● Safety is primary concern
● Watch for overt cues of suicide (Obvious) active
● Covert cues are more subtle—passive
● People who suddenly are happier are of great concern; may have made the
suicidal plan are content with their decision.
● People whose meds are finally working—have enough energy to carry out the act
Client’s Affect
● Compare verbal with non-verbal behaviors—do they match up?
● Asocial: Withdrawal from family and friends
● Anhedonic: Lose sense of pleasure
● When confronting these client’s about their behavior, use “I” statements
○ “I really wish you’d join the group”
Judgment
● Feel overwhelmed with normal activities
● Difficulty with task completion
● Always exhausted
Self Concept
● Ruminate: Worry to excess.
● Lack energy for normal activities (always tired)
Interventions
● Assess safety for client (PRIORITY!)
● Perform suicide lethality assessment
● Orient client to new surroundings (they need structure)
● Offer explanations of unit routine (again, need structure)
Withdrawal
● Two purposes:
○ Safe withdrawal with medication
■ Suppress symptoms of abstinence
■ Around the clock schedule and PRN
■ Never, ever go cold turkey.
○ Prevent relapse
■ May need to go to AA for rest of life.
Cognitive disorders
Delirium
● Disturbance of consciousness accompanied by change in cognition; disoriented
○ Alert and oriented to person only
○ Typically have problems recalling on memory and time.
● Develops over a short period of time
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● Easily distracted
● Difficulty concentrating
● Illusions, hallucinations
● Onset is rapid
● Brief duration
● Level of consciousness is impaired
● Slurred speech
● Anxious mood
Causes of Delirium
● Metabolic
● Infection—UTI
● Low sodium
○ Normal is 135-145 mEq/L
○ Always check electrolytes!
● Drug related
○ Or, withdrawal from drugs and alcohol
○ Sedatives and benzodiazepines cause confusion
● Effects of anesthesia
The nursing process: Assessment
● Interview with simple questions and explanations
● Frequent breaks
● History of onset; not reliable from client
○ Interview family members; ask: “Is the how your mom typically acts?”
● Mood/Affect
○ Frequently assess moods; moods change quickly
● Thought process/content
○ Many have visual hallucinations
○ Very restless; hard to keep in bed.
Nursing process: Goals
● Free from injury
○ Fall precautions
● Demonstrate increased orientation
○ Use reality orientation and validate feelings
● Adequate balance of activity and rest
○ Help the patient keep days and nights straight
● Adequate nutrition
○ Often forget to eat; needs nutritional supplements
● Return to optimal level of functioning
● A goal needs a timeline to make it measurable!
Nursing process: Intervention
● Patient safety
● Managing confusion
○ Often frightened at night.
● Promote comfort and rest
● Adequate fluids and nutrition
○ Always offer little sips of water!
Nursing process: Evaluation
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● Successful treatment of underlying causes for delirium returns client to former
level of functioning
● Client and family education about avoidance of recurrence
● Monitor chronic health problems
● Careful use of medications
● No alcohol or other non-prescribed drugs
Dementia
Dementia
● More progressive, gradual, and permanent
● Involves multiple cognitive deficits
○ Primarily memory impairment
● Involves at least one of the following:
○ Asphasia (deterioration of language function)
○ Apraxia (impaired ability to execute motor functions)
○ Agnosia (inability to name or recognize objects)
○ Disturbance in executive functioning (ability to think abstractly and to
plan, initiate, sequence, monitor, and stop complex behavior)
● May also present:
○ Echolalia (echoing what is heard)
○ Palilalia (repeating words or sounds over and over)
Schizophrenia
Types of schizophrenia
● Paranoid schizophrenia
○ Suspiciousness
○ Hostility
○ Delusions
○ Auditory hallucinations
○ Anxiety and anger
○ Aloofness
○ Persecutory schemes
○ Violence
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● Disorganized schizophrenia
○ Extreme social withdrawal
○ Disorganized speech or behavior
○ Flat or inappropriate affect
○ Silliness unrelated to speech
○ Stereotyped behaviors
○ Grimacing mannerisms
○ Inability to perform activities of daily living
● Catatonic schizophrenia
○ Significant psychomotor disturbances
○ Immobility
○ Stupor
○ Waxy flexibility
○ Excessive purposeless motor activity
○ Echolalia
○ Automatic obedience
○ Stereotyped or repetitive behavior
● Undifferentiated schizophrenia
○ Undifferentiated schizophrenia does not meet the criteria for paranoid,
disorganized, or catatonic schizophrenia
○ Delusions and hallucinations
○ Disorganized speech
○ Disorganized or catatonic behavior
○ Flat affect
○ Social withdrawal
● Residual schizophrenia
○ Diagnosed as schizophrenic in the past
○ Time limited between attacks but may last for many years
○ The client exhibits considerable social isolation and withdrawal and
impaired role functioning
Interventions
● Assess the client’s physical needs
● Set limits on the client’s behaviors when it interferes with others and becomes
disruptive
● Maintain a safe environment
● Initiate one-on-one interaction and progress to small groups as tolerated
○ Although, reintegrating the client into the milieu as soon as possible is
essential
● Spend time with the client even if client is unable to respond
● Monitor for altered thought processes
● Maintain ego boundaries and avoid touching the client
○ Touching others without warning or invitation
○ Intruding in others’ living spaces
○ Talking to or caressing inanimate objects
○ Undressing, masturbating, or urinating in public
● Limit the time of interaction with the client
○ Initially, the client may only tolerate 5-10 minutes of contact at one time.
● Avoid an overly-warm approach; a neutral approach is less threatening
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● Do not make promises to the client that cannot be kept
● Establish daily routines
● Assist the client to improve grooming and to accept responsibility for self-care
● Sit with the client in silence if necessary
● Provide short, brief and frequent contact with the client
● Tell the client when you are leaving
● Tell the client when you do not understand
● Do not “go along” with the clients delusions or hallucinations
● Provide simple concrete activities such as puzzles or word games
● Reorient the client as necessary
● Help the client establish what is real and unreal
● Stay with the client if he is frightened
● Speak to the client in a simple direct and concise manner
● Reassure the client that the environment is safe
● Remove the client from group situations if the client’s behavior is too bizarre,
disturbing, or dangerous to others
○ Reassure others that the client’s inappropriate behaviors or comments are
not his fault (without violating confidentiality).
● Set realistic goals
● Initially do not offer choices to the client, and gradually assist the client in making
own decisions
● Use canned or packaged food, especially with the paranoid schizophrenic client
● Provide a radio or tape player at night for insomnia
● Explain to the client everything that is being done
● Set limits on the client behavior if the client is unable to do so
● Decrease excessive stimuli in the environment
● Monitor for suicide risk
● Assist the client to use alternative means to express feelings through must or art
therapy or writing.
Nursing interventions for the client experiencing delusions
● Ask the client to describe the delusion
● Be open and honest in interactions to reduce suspiciousness
● Focus the conversation on reality based topics rather than the delusion
● Encourage the client to express feelings and focus on the feelings that the
delusions generate
● If the client obsesses on the delusion, set firm limits on the amount of time for
talking about the delusion
● Do not dispute with the client or try to convince the client that the delusions are
false
● Validate if part of the delusion is real
● Recognize accomplishments and provide positive feedback for successes
Nursing interventions for the client experiencing hallucinations
● Monitor for hallucination cues
○ See blue box on page 296
● Elicit description of hallucination to protect the client and others
○ The nurses understanding of the hallucination helps the nurse know how
to calm or reassure the client
● Intervene with one on one contact
Eating disorders
The distinguishing factor of anorexia includes an earlier age of onset and below-normal
body weight; the person fails to recognize the eating behavior as a problem. Clients with
bulimia have a latter age at onset and a near-normal body weight. They usually are
ashamed and embarrassed by the eating disorder.
Eating disorders appear to be equally common among Hispanic and white women and
less common among African American and Asian women.
Anorexia Nervosa
● A life-threatening eating disorder characterized by the client’s refusal or inability
to maintain a minimally normal body weight, intense fear of gaining weight or
becoming fat, significantly disturbed perception of the shape or size of the body,
and steadfast inability or refusal to acknowledge the seriousness of the problem or
even that one exists.
● Has experienced amenorrhea for at least 3 consecutive cycles
● Complaints of constipations and abdominal pain
● Cold intolerance
● Hypotension, hypothermia, bradycardia
○ Intravascular volume is decreased; less blood to pump through heart, also
due to excessive exercise
● Elevated BUN
○ Normal levels: 10-20 mg/dl
○ Urea is formed in the liver and is the end product of protein metabolism.
○ In anorexia, the body has already used fat for energy; it is now breaking
down muscles for energy—the reason for the elevated BUN
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● Decreased albumin
○ Normal levels: 3.5-5 g/dl
○ Measures amount of protein in the body; albumin is a protein formed in
the liver.
○ Albumin tests are a great indicator of nutritional status
● Leukopenia and mild anemia
○ Not enough food and nutrients to replenish cells
● Has a preoccupation with food and food-related activities
● Can be divided into 2 subgroups:
○ Restricting subtype: lose weight primarily through dieting, fasting, or
excessively exercising.
○ Binge eating and purging subtype: engage regularly in binge eating
followed by purging.
● Engage in unusual or ritualistic food behaviors
○ Refusing to eat around others
○ Cutting food into minute pieces
○ Not allowing the food they eat to touch their lips
● Excessive exercise is common
● Diagnosed between 14 and 18 years of age
● Pleased with their ability to control their weight and may express this.
● As the illness progresses, depression and lability in mood become more apparent
● Isolate themselves
● Believe peers are jealous of their weight loss and believe family and health care
professionals are trying to make them “fat and ugly”.
● Clients who use laxatives are at a greater risk for medical complications.
● Autonomy may be difficult in families that are overprotective or in with
enmeshment (lack of clear boundaries) exists. By losing weight, these clients
have some control in their lives.
● Have body image disturbance (page 409)
● Can be very difficult to treat because they are often resistant, appear uninterested,
and deny their problems.
● Treatment:
○ Focusing on weight restoration
○ Nutritional rehabilitation
○ Rehydration
○ Correction of electrolyte imbalances
○ Severely malnourished individuals may require TPN, tube feedings, or
hyperalimentation to receive adequate nutritional intake.
○ Access to the bathroom is supervised to prevent purging as clients begin to
eat more food.
○ Weight gain and adequate food intake are most often the criteria for
determining the effectiveness of treatment.
○ Amitriptyline (Elavil) and the antihistamine cyproheptadine (Periactin) in
high doses (up to 28mg/d) can promote weight gain in inpatients.
○ Olanzapine (Zyprexa) has been used with success because of both its
antipsychotic effect (on bizarre body image distortions) and associated
weight gain.
Somatoform disorders
Somatization: The transference of mental experiences and states into bodily symptoms.
Somatoform disorders: Characterized as the presence of physical symptoms that
suggest a medical condition without demonstrable organic basis to account fully for
them. The three central features of somatoform disorders are as follows:
● Physical complaints suggest major medical illness but have no demonstrable
organic basis.
● Psychological factors and conflicts seem important in initiating, exacerbating, and
maintaining the symptoms.