EBP (evidence based practice) Using the best available research evidence, clinical expertise, & patient preferences to make clinical decisions The 5 A’s of integrating best evidence into clinical practices includes: Asking Acquiring Appraising Applying Assessing The mental health recovery model is one of helping people with psychiatric disabilities effectively manage their symptoms, reduce psychosocial disability, and find a meaningful life in a community of their choosing. 3 specific areas are inherent within the art of nursing: caring, attending & patient advocacy.  Basic Brain Anatomy- what do the different part of brain control? o Frontal Lobe: Thought Processes & Voluntary Movement (decision making) o Temporal Lobe: Auditory Processes (language, speech, connects to Limbic system) o Occipital Lobe: Vision (interprets visual images) o Parietal Lobe: Sensory & Motor (L/R orientation, reading, math, proprioception) o Hypothalamus: maintains homeostasis, regulates BP, Temp, libido, hunger, thirst, and sleep/wake cycles. o Cerebellum: Balance, Skeletal Muscle Coordination o Neurons: Nerves that translate electrical impulses into chemical signals released at the synapse  Synapse- The space between neurons in which neurotransmitters are released and either inhibit/excite the adjacent neuron. The 4 NT’s are dopamine, norepinephrine, serotonin and acetylcholine.  Milieu Therapy: Creating a SAFE, structured inpatient/outpatient setting where the mentally ill can test new behaviors and coping mechanisms with others. o Climate is essential to healing: paint color, relaxed environments are conducive to the healing process. o Florence Nightingale believed that the environment helps heal  Maslow’s Hierarchy of needs o Basic Needs: food, oxygen, water, sleep, sex, and a constant body temperature. If all the needs were deprived, this level would take priority. o Safety Needs: Security, protection, freedom from fear/anxiety/chaos, and the need for law, order, and limits. o Belonging and Love Needs: intimate relationship, love, affection, and belonging, having a family and a home and being part of identifiable groups. o Esteem Needs: If self-esteem needs are met, we feel confident, valued, and valuable. When self-esteem is compromised, we feel inferior, worthless, and helpless. o Self-actualization: Reaching our full potential to feel inner peace and fulfillment.  Peplau’s Theory of Interpersonal Relations o Created the Nurse-Patient Partnership increasing individual and family roles in recovery. (Based off of Sullivan’s Interpersonal Theory). Relationships greatly influence recovery  Freud- contributed to psychiatric setting -Unconscious thoughts o Id – unconscious mind, instincts (this is dominant) o Ego – sense of self, use of defense mechanisms o Superego – our conscious and is greatly influenced by our parents morals and ethical stances Downloaded by SAMUEL WAM (samek2029@gmail.com) lOMoARcPSD|13778330 Mental Health FINAL EXAM Study Guide – A 2  Erickson’s o Trust vs. Mistrust (infant 0- 1 ½) trust developed if caregivers give affection, love, care, attention, and reliability. (Feeding) o Autonomy vs. Shame (toddlers 1 ½ - 3) kids need to develop a sense of personal control. (Toilet Training) o Initiative vs. Guilt (children 3-6) children need to have power to explore their environment and not receive disapproval from parents. (Exploration) o Industry vs. Inferiority: (school aged kids 6-12) Kids dealing with new social and academic demands. Success leads to a sense of competence. (School) o Identity vs. Role Confusion (teens 12-20) Teens need to develop self-identity and personal identity to stay true to themselves. (Social Relationships) o Intimacy & Solidarity vs. Isolation (young adults 20-30) Young Adults need to form intimate, loving relationships. (Relationships) o Generativity vs. Self-Absorption: (adults 30-65) Need to create/nurture things by having children. (Work & Parenthood) o Integrity vs. Despair (elderly 65+) Need to look back and feel fulfilled by accomplishments; have wisdom and no regrets (Reflection on Life)  Sullivan Personalities are influenced during childhood and mostly by the MOTHER.  Therapeutic Communication: goal directed, professional, scientifically based. The goal is to get information so that you can plan care for the patient. o Active Listening  Clarifying: promotes understanding of the patient’s statement  Restating: repeating the same key words the patient has just spoken to echo their feelings. (Ex: If a patient remarks, “My life is empty…it has no meaning,” additional information may be gained by restating, “Your life has no meaning?”)  Reflecting: helps people understand their own thoughts better; summarizes (Ex: For example, to reflect a patient's feelings about his or her life, a good beginning might be, “You sound as if you have had many disappointments.”)  Exploring: use of open-ended questions or statements to allow the patient to express thoughts/feelings. (Ex: “Tell me more…”, “Give me an example of…”)  Communication Technique Examples in Different Scenarios o For Suicidal Patients: “These thoughts are very serious Mr. Adams. I do not want any harm to come to you. Can you tell me what you were feeling and if there were any circumstances that led you to this decision?” o For Patients who start Crying: Stay with your patient and reinforce that it is all right to cry & offer tissues. “You seem upset, what are you thinking right now?” o For Patients who say they “don’t want to talk”: “Its alright. I would like to spend time with you. We don’t have to talk.” Or reapproach at a later time, “Our 5 minutes is up. I will be back at 10am and spend another 5 minutes with you.” o For Patients who ask the nurse to keep a secret: Nurses cannot make such promises, as it may be important to share that information with other staff for safety reasons. “I cannot make that promise Mr. Adams as it might be important for me to share it with the other staff”. o Non-Verbal:  Tone of voice (tone, pitch, intensity, stuttering, silence, pausing)  Facial expressions (frown, smile, grimaces, raises eyebrows, licks lips)  Posture (slumps over, puts face in hands, taps feet, fidgets with fingers)  Amount of eye contact (angry, suspicious or accusatory looks, wandering)  Sighs/Hand gestures (fidgeting, snapping fingers)  Yawning Downloaded by SAMUEL WAM (samek2029@gmail.com) lOMoARcPSD|13778330 Mental Health FINAL EXAM Study Guide – A 3  Non-Therapeutic Communication: not goal-directed, false reassurances, double messages, giving personal opinions, making assumptions of feelings, asking “Why” questions, showing disapproval, excessive questioning, non-attending behaviors, poor non-verbal communication (eye rolling, staring off into distance, ignoring patient). o Double Bind Messages: intent of the message is to cause confusion o Double Messages: conflicting/mixed messages o Giving premature advice o Presenting reality and focusing  Phases of the Nurse-Patient Relationships o Orientation Phase: first time the nurse & patient meet, interact according to their own backgrounds/standards/values/beliefs, roles of the patient and nurse are clarified, confidentiality is discussed and assumed, nurse becomes aware of transferences & countertransference issues, goals are established, termination terms are introduced. o Working Phase: exploration of feelings or situations that are causing the problems, re-experiencing of old conflicts can awaken high levels of anxiety, intense emotional states may surface, defense mechanisms, denying, manipulation, evaluation of problems and goals, promote alternative reactions/behaviors to situations, etc. The nurse’s awareness of his or her own personal feelings and reactions to the patient are VITAL for effective interaction with the patient. o Termination Phase: summarization of goals, review of what was achieved during communication, discussing new ways to implement new coping strategies, evokes strong feelings in both client & nurse.  Legal, Ethical, and Cultural o Negligence –or malpractice is an act or an omission to act that breaches the duty of due care and results in or is responsible for a person’s injuries. The five elements required to prove negligence are: (1) duty, (2) breach of duty, (3) cause in fact, (4) proximate cause, and (5) damages.  Example – A nurse know that a patient’s IV is malfunctioning and the wires are frayed, but decides not to act in a timely manner and leaves the IV on the patient and doesn’t tag it for repair, this results in the patient dying. o Beneficence - This relates to the quality of doing good and can be described as charity.  Example - A nurse helps a newly admitted client who has psychosis feel safe in the environment of the mental health facility. o Autonomy - This refers to the client’s right to make her own decisions. But the client must accept the consequences of those decisions. The client must also respect the decisions of others.  Example - Rather than giving advice to a client who has difficulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice. o Justice - This is defined as fair and equal treatment for all.  Example - During a treatment team meeting, a nurse leads a discussion regarding whether or not two clients who broke the same facility rule were treated equally. o Fidelity - This relates to loyalty and faithfulness to the client and to one’s duty.  Example - A client asks a nurse to be present when he talks to his mother for the first time in a year. The nurse remains with the client during this interaction. o Veracity - This refers to being honest when dealing with a client.  Example - A client states, “You and that other staff member were talking about me, weren’t you?” The nurse truthfully replies, “We were discussing ways to help you relate to the other clients in a more positive way.”  Rights for Voluntary and Involuntary Admission o Voluntary Commitment – The client or client’s guardian chooses commitment to a mental health facility in order to obtain treatment. A voluntarily committed client has the right to apply for release at any time. This client is considered competent, and so has the right to refuse medication and treatment. o Involuntary (civil) Commitment – The client enters the mental health facility against her will for an indefinite period of time. The commitment is based on the client’s need for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care. The need for commitment could be Downloaded by SAMUEL WAM (samek2029@gmail.com) lOMoARcPSD|13778330 Mental Health FINAL EXAM Study Guide – A 4 determined by a judge of the court or by another agency. The number of physicians, which is usually two, required to certify that the client’s condition requires commitment varies from state to state. Clients admitted under involuntary commitment are still considered competent and have the right to refuse treatment, unless they have gone through a legal competency hearing and have been judged incompetent