Study Guide
Module 1 (History and Policies)
1. History/Asylums
a. Asylums were facilities to care for those with mental illness
b. After being admitted, it is hard to get discharged
c. 1950’s phenothiazines were introduced, anti-psychotic medication used to treat serious
mental and emotional disorders, including schizophrenia and other psychotic disorders.
d. Patients had no “rights” and went ahead with the procedures even without consent of
patient or family
e. Homelessnes
2. Core Concepts: Some Definitions
a. Ethics: A branch of philosophy that deals with distinguishing right from wrong
b. Bioethics: Term applied to ethic when they refer to concepts within the scope of
medicine, nursing, and allied health
c. Moral Behavior: Conduct that results from serious critical thinking about how
individuals should treat others
i. Your morals affect how you treat clients in care
d. Values: Personal beliefs about what is important and desirable
i. Your personal beliefs affect clients in your care
e. Autonomy: emphasizes that status of persons as autonomous moral agents whose rights
to determine their destinies should always be respected
f. Beneficence: refers to one’s duty to benefit or promote the good of others.
g. Legal right: a right in which society has agreed and formalized into law
3. Development “Laws and Policies” (why were these developed)
a. To protect the patients, we must know it as well and how to navigate in the document to
be able to understand each law and policies
4. Certified Patient/Client (Why do you need to know these)
a. Keep them safe and people around them
b. The Chart/3 criteria:
i. The person is suffering from a mental disorder
ii. The person is likely to cause harm to self or others to suffer substantial mental or
physical deterioration or serious physical impairment
iii. Ther person is unsuitable for admission to a facility other than as a formal patient
(in the case of an admission certificate)
c. Stages of certification:
i. EMERG: 24 hours (2 physicians)
ii. Sending to the unit: 24 hours (1 physician and 1 psychiatrist)
iii. Unit: 1 month
iv. 1 month
v. 6 months
d. Why is it important for Emergency Department staff to note the time of arrival of any
patient?
i. To take note of end of time of expiry of certification
e. Why is it important for nursing staff on units to note the time of “each certification”?
i. The patient can leave if they don’t get certified by the 2 physicians again
f. A client can be certified if they are intoxicated or impaired by drugs/alcohol
g. Review Panel:
i. Intended to be a way of getting decisions made based on a fair and objective
review of your situation. It includes:
1. One Lawyer
2. A Medical Doctor
3. A Psychiatrist
4. A member of the general public
h. “Healthcare professionals” under the Persons in Protective Care Act:
i. Obligation to report abuse; they also have a duty to take reasonable steps to
protect the client from abuse and maintain a reasonable level of safety for the
client and take all reasonable steps to provide for the immediate safety, security
and well-being of the client and any other client.
i. Missing Person Act
5. 8 Rights:
a. Information: when two admission and renewal certificates are issued, you must be told
what the reasons. Also, you must be told about your right to appeal to the Review
Panel for cancellation of the Certificate. Relative or Guardian must be given this
information (but you can also prevent them from giving any information from these
people). You can also choose a person to give the information to. If there is language
barriers, the hospital must obtain an interpreter to be able to provide you with the
information in your language.
b. Confidentiality: Hospital records must remain private.
c. Communications: Hospital staff cannot open or hold back your mail or deny you the use
of the telephone. (Unless you are abusing this use)
d. Visitors: you may have visitors during set visiting hours. The only limit is if your
physician feels that a specific visitor is harmful to you.
e. Legal Representation: You have the right to have a lawyer represent you, and your
lawyer may visit you at any reasonable time. If you cannot afford a lawyer, you may have
access to one through Legal Aid.
f. Refuse treatment: You have the right to refuse treatment if you are found to be competent
to make decisions about your treatment. If you are deemed incompetent, and treatment is
consented to by your nearest relative, you may object to the treatment by appealing the
incompetence issue to the Review Panel. Psychosurgery can never be performed without
your consent.
g. Appeal: You have the right to appeal to the Review Panel all decisions regarding your
certification, admission, renewal, or competence. If you are not satisfied with your
Review Panel hearing, you have the right to appeal the Panel’s decision to the Court of
Queen’s Bench.
h. Have an advocate
6. Alberta Health Services vs CLPNA
a. CLPNA
i. It governs your Nursing License
ii. CLPNA has a Code of Ethics
iii. Your conduct as a professional nurse can be affected if you are not following the
policies of AHS or you are violating the code of ethics
b. AHS
i. Is responsible to implementing policies and guidelines which healthcare
professionals must follow
ii. Nurses are expected to access these policies when caring for clients
iii. If nurses are not following the policies, they are putting patients at risk, and also
potentially risk losing their license
7. Restraint Policy
a. Chemical Restraints
b. What do we mean by “Security Constant”
c. How often do you check a client in restraints?
d. What is the Policy regarding restraints?
e. Can you apply them whenever you want?
Module 2 (Communication Boundaries & Cultural and Spiritual Concepts)
1. Mental Health Definition
a. Defined as “the successful adaptation to stressors” from the internal and external
environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and
congruent with local and cultural norms.
b. Stressors examples:
i. For students: Exams, due dates, financial stability
c. Maslow identified
i. A “hierarchy of needs”
A. Self-actualization (as fulfillment of one’s highest potential)
B. Esteem
C. Love/Belonging
D. Safety
E. Physiological
2. Mental Illness Definition
a. Defined as “maladaptive responses to stressors”, it interferes with the individual’s social,
occupational, or physical functioning
b. Culture does have impact on how people view mental illness
3. Response to stress:
a. Example stressors for students:
Stress
- Finance, Food, Sleep
Deprivation, School/Work,
Relationship, Balancing
Questions
Relieve Your Anxiety
- Therapy, Plan Schedule,
Exercise, Self-Care,
Alcohol, Partying, Eating
*Some are not good
overtime
b. There are two types of response to stress
i. Physical (Fight-or-flight" syndrome)
Anxiety
- thinking/ feeling, quiet,
fidgeting, not easy to
eliminate or remove
ii. Psychological (Anxiety and grief)
• Peplau’s four levels of anxiety
• 5 stages of grief
a. Denial
b. Anger
c. Bargaining
d. Depression
e. Acceptance
c. Defense Mechanisms Worksheet
4. Legal Issues for people suffering from mental illness:
a. Confidentiality and right to privacy
b. Restraints and seclusion
c. Chemical Restraints
d. Observations levels
5. Professional Boundaries
a. Do not disclose any personal information: you may think that you are
b. Distance – 3 feet “Space”
c. Do not accept any gift/money from your patient
d. Touch: No hugging or any form of relationship
e. Warning Signs:
i. Favoring one client’s care over another’s
ii. Keeping streets with a client
iii. Changing dress style for working with a particular client
iv. Swapping client assignment
v. Giving special attention
vi. Sharing personal information
vii. Frequently thinking about the client when away from work
6. Communication
a. Nurse-client relationship is the foundation on which nursing is established, but even more
so when caring for clients with mental health disorders
b. It is the #1 tool in nursing, your communication and exchanging of information with the
client and family members stands a very important role
c. Nurse-Client Relationship: (can review textbook)
i. Rapport: Non-Judgmental Look
ii. Trust: Mental health patients vs Surgical patient, history and trust issues.
A. Make sure to give them space
B. Communication, letting them know about everything
C. “concrete” does things that you tell them (be specific)
iii. Respect
iv. Genuineness
v. Empathy (not the same as sympathy)
A. Empathy: it is also like putting yourself in their shoes and trying to help
them. “I really don’t know what to say, but I’m glad you told me”
B. Sympathy: Feeling sorry for them. “Trying to find something to say to
them”
vi. Different Phases:
A. Pre-interaction phase
B. Orientation (introductory) phase
C. Working Phase
D. Termination Phase
7. Maslow’s hierarchy needs and how it impacts therapeutic relationships
8. DSM
a. Diagnostic Statistical Manuel of Mental Disorders, it is a manual used by Physicians,
Psychiatrists, Psychologists to diagnose mental disorders
9. Cultural Concepts
a. Nurses must understand these cultural concepts because cultural influences affect
human behavior, the interpretation of human behavior, and the response to human
behavior
b. Never assume that all individuals who share a culture or ethnic group are the same.
(Stereotypes)
c. How do cultures differ?
i. Communication
ii. Space
iii. Social organizations
iv. Time
d. Different Cultures
i. Indigenous
A. No touch, handshake views as aggressive and eye contact is considered
rude
B. Appear silent and reserved
C. Uncomfortable expressing emotions
a. Children are taught to respect tradition
b. “Present-time” oriented
c. “elders” of tribe are highly respected
ii. Asian
A. Family is the ultimate social organization and loyalty to family is one of
the biggest musts.
B. Education is prioritized. Many remain undereducated
C. Religious practices and beliefs are diverse
a. Taoism
b. Confucianism
c. Hinduism
d. Buddhism
e. Islam
f. Christianity
D. Psychiatric illness is viewed as behavior that is out of control and brings
great shame to the family
iii. Arab
A. Time is present-oriented, punctuality is taken seriously in the case of
business or professional meetings
B. Man is the head of the household, women are subordinate to men
C. Women value modesty, and wears Hijab.
D. Islam is the religion of most Arab countries. Spiritual medicine
E. Mental illness is a major social stigma and symptoms are likely to be
presented as physical complaints
e. Cultural-bound syndromes
i. Culture bound syndromes have unique physical or behavioral manifestations
that are unique to that particular culture
f. Spiritual Needs
i. Meaning and purpose in life
ii. Faith
iii. Love
iv. Forgiveness
A. Long-held feelings of bitterness and resentment can have a
detrimental effect on an individual’s health
v. Religion
Module 3 (Biological Implications)
1. Introduction
a. Psychobiology: area of study of biological of mental health
2. The Brain
a. Forebrain (Frontal lobe)
i. Plays an essential role in regulation and adaptation of our emotions
ii. “Your Personality”
iii. People with mental illness: Frontal lobe is different. Think about their emotions
and adaptation to things
b. Circadian Rhythms (sleep patterns)
i. People with mental illness, disruption of circadian rhythm occurs and
sometimes first to appear amongst other symptoms. (Depression and Unable to
sleep)
c. Pituitary gland (related to Circadian Rhythms)
i. CR disruption may influence a variety of regulatory functions
3.
4.
5.
6.
d. Diencephalon
e. Limbic System
i. “Emotional brain”
ii. It is associated with feelings of fear, anxiety, rage, aggression, love, joy, hope
iii. Amygdala: fear, anxiety, and panic
Synapse/neurotransmitters
a. Reuptate = “Reabsorption”
i. Serotonin does not get transported to the next neurotransmitter and so
serotonin is reabsorbed in myelin sheath back to the neurotransmitter
b. Neurotransmitter worksheet
i. What is the increase and decrease in certain medications are
c. Synapse: the junction between two neurons
d. The “study of the transmission of neurotransmitters”, is relevant as it is the “primary
site” for psychotropic medications
i. They focus on the chemicals in the brain to help them regulate it
e. The autonomic nervous system:
i. The sympathetic division (Flight/fight)
A. Dominant in stressful situations
ii. The parasympathetic division (Rest and digest)
A. Dominant in relaxed situations
Psychopharmacology
a. Most action occurs at the neuronal synapse
i. Antidepressants
ii. Antipsychotics
iii. Benzodiazepines
iv. Psychostimulants
b. *Remember that everyone is different, so it is a “trial and error”. One the works for
someone, does not guarantee that it will work for you as well
c. Patients eventually get frustrated because of the side effects of medications
Genetics:
a. Familial Link: it doesn’t mean you develop it because your family had it
b. Studies of some disorders indicate there is a familial link to some illnesses such as
i. Alcoholism
ii. Depression
iii. Schizophrenia
iv. *The following can also impact developing the above, psychosocial,
sociocultural and biological influences
c. Society is more aware than ever before of mental illness. The positive outcome is with
more education, families are more aware
Diagnostic Procedures (*Use to rule out brain tumor or brain bleed)
a. Electroencephalography (EEG): detect seizures
b. Computerized EEG mapping
c. Computed tomographic scan (CT scans): look at different body systems, Brain bleeds
d. Magnetic resonance imaging (MRI): for brain, cuts brain into slices, make sure there are
no metals when coming in for MRI test
e. Positron emission tomography (PET scan): “colors of the brain”, detects “warm and
cold”, Ask for allergies (ex. Dye)
f. Single photon emission computed tomography
Module 4 (Schizophrenia Spectrum and Other Psychotic Disorders)
1. Introduction:
a. Greek words Skhizo (split) and phren (mind)
b. Factors:
i. Genetic predisposition
A. The risk for general population is approximately 1% as compared to
those with a sibling having a 10% risk
ii. Biochemical dysfunction
A. One theory suggests that schizophrenia may be caused by an excess of
dopamine activity in the brain
B. Abnormalities in other neurotransmitters (?)
iii. Physiological factors
A. Viral infection
B. Anatomical abnormalities
C. Histological changes in the brain
iv. Psychosocial stress
A. These theories no longer hold credibility, they focus more of it as a
“brain disorder”
c. DSM-VI
i. Identifies schizophrenia “on a spectrum” meaning different levels and different
symptoms
d. Of all mental illnesses, it causes more:
i. Lengthy hospitalizations
A. Hospitalizations may be necessary if individual is no longer coping in
community setting or at home
B. Auditory hallucinations are the most dangerous as they often tell the
individual repeatedly that they need to die
ii. Chaos in family life
iii. Fears
iv. Potential for suicide is a major concern
e. Prognosis:
i. 1/3: will have 1 episode of psychosis
A. Respond to meds → achieve lasting improvement
ii. 1/3: some improvement
A. With relapses (may not be able to return to prior occupation – may have
residual disability)
iii. 1/3: will not respond
A. Will go on to develop severe incapacity, will remain severely ill
2. Signs and Symptoms:
a. Develops often in adolescence
b. Stages: progresses until “Psychosis”
i. Psychosis → can develop with other illnesses, not just with schizophrenia such
as drug withdrawal, alcohol withdrawal, and medications
c. *Psychosis is what brings them to the hospital by their family
3. Nature of disorder
a. Causes disturbance in:
i. Thought processes (disorganized thoughts)
ii. Perception (hearing voices when no one is there)
iii. Affect (affects emotions)
b. There is a severe deterioration of social and occupational functioning
i. Not being able to cope or connect with other people
c. The pattern of development (4):
i. Premorbid phase
A. Can be difficult to tell if it is personality traits or behaviors
ii. Prodromal phase
A. Sleep disturbance, anxiety, irritability
B. Social withdrawal
C. Can last 2-5 years
D. Obsessive compulsive disorder: coping mechanisms for anxiety
E. Can be mistaken for depression, anxiety, which in this age group is
common
iii. “Active psychotic” phase (schizophrenia)
A. Psychotic symptoms are prominent
a. Delusions: are fixed beliefs
i. Persecutory
ii. Reference
iii. Thought insertion
b. Hallucinations: auditory, visual, tactile, and at times smell
i. Auditory are the worst as often command the person
c. Impairment in work, social relations, and self-care
d. Cognition impaired so unable to think abstract; problem solve;
social interactions
e. Severity of cognitive impairment is a major determinant of
overall disability
f. Hygiene starts to go away
iv. Residual phase
A. Similar to those of the prodromal phase
B. Negative symptoms such as flat affect and impairment in role
functioning are prominent
C. The more psychosis they go through, the more residual impairment
increases.
4. Positive and Negative Symptoms (negative develop first then positive after)
5. Cannabis and Genetic Vulnerability
a. Research is linking heavy marijuana use to schizophrenia and paranoid psychosis
particularly on brains of those who are younger than ages 14 and 15
b. Evidence shows that use of this increases the risk of psychosis by up to 700 %
6. Medications:
a. Requires life-long treatment, even when symptoms have subsided
b. Antipsychotics are still the preferred choice in treatment for schizophrenia and the goal
is lowest dose possible to manage s/s
c. However, patients eventually stop taking medication because of some of the side effects
such as weight gain
d. How Do They Work?
i. Neuroleptics (chlorpromazine and Haldol) lower brain levels of dopamine by
blocking dopamine receptors, and thereby reducing schizophrenia symptoms
such as hallucinations. (However, it does not manage all the symptoms)
e. Several types to manage:
i. Antipsychotics: relieve psychotic episodes, also Parkinson type body
movements (antiparkinson) To help restore the natural balance of acetylcholine
and dopamine in the CNS
ii. Benzodiazepines: promotes relaxation
iii. Antidepressants: given if pt. Diagnosed with depression along with
schizophrenia
f. What each medication does in the body:
i. Slide 35