RN 65 – NURSING CARE OF THE CLIENT WITH BEHAVIORAL AND EMOTIONAL DISORDERS FRESNO CITY COLLEGE (FCC) CHAPTER 1 – MENTAL HEALTH AND MENTAL ILLNESS CHAPTER 1 – MENTAL HEALTH AND MENTAL ILLNESS Objectives 1. Define mental health and mental illness 2. Describe the continuum of mental health and mental illness 3. Discuss risk and protective factors for mental illness and mental health 4. Explore the role of resilience in the 6. Discuss the nature / nurture origins of psychiatric disorders. 7. Summarize the social influences of mental healthcare in the United States. 8. Discuss the role of public policy on mental health funding. 9. Explain how epidemiological knowledge supports mental healthcare. prevention of and recovery from mental illness 10. Identify how the Diagnostic and Statistical and consider resilience in response to stress. Manual Fifth Edition (DSM-5) is used for 5. Identify how culture influence the view of diagnosing psychiatric conditions. mental illnesses and behaviors associated with 11. Described the specialty of psychiatricthem. mental health nursing WHAT IS THE DSM-5? The Diagnostic and Statistical Manual of Mental Disorders, DSM-5, is the current official guidebook for categorizing and diagnosing psychiatric mental health disorders in the United States. The DSM-5 provides clinicians, researchers, regulatory agencies, health insurance companies, pharmacological companies, and policy makers with a standard language and criteria for the classification of mental disorders. MULTI-AXIAL SYSTEM Axis I: provided information about clinical disorders. Any mental health conditions, other than personality disorders or mental retardation, would have been included here. (Ex. mood disorders, anxiety disorders or psychotic disorders) Axis II: provided information about personality disorders and mental retardation. (Ex. borderline personality disorders or mental retardation) Axis III: provided information about any medical conditions that were present which might impact the patient's mental disorder or its management. (Ex. hypothyroidism) Axis IV: describe psychosocial and environmental factors affecting the person (Ex. education problem, housing problems or economic problems) Axis V: Global Assessment of Functioning (GAF) from 0 to 100 and provided a way to summarize in a single number just how well the person was functioning overall. GLOBAL ASSESSMENT OF FUNCTIONING (GAF) 100: No symptoms 90: Minimal symptoms with good functioning 80: Transient symptoms that are expected reactions to psychosocial stressors 70: Mild symptoms or some difficulty in social occupational or school functioning 40: Some impairment in reality testing or communication or major impairment in several areas such as work or school, family relations, judgment, thinking or mood 30: Behavior is considerably influenced by delusions or hallucinations or serious impairment in communication or judgment or inability to function in almost all areas 60: Moderate symptoms or moderate difficulty 20: Some danger of hurting self or others or in social, occupation or school functioning 50: Serious symptoms or any serious impairment in social occupational or school functioning occasionally fails to maintain minimal personal hygiene or gross impairment in communication 10: Persistent danger of severely hurting self or others or persistent inability to maintain minimal personal hygiene or serious suicidal act with clear expectation of death MENTAL ILLNESS Refers to all psychiatric disorders that have definable diagnoses. These disorders are manifested in significant dysfunctions that may be related to developmental, biological, psychological disturbances in mental functioning The ability to think may be impaired ATTRIBUTES OF MENTAL HEALTH Good mental health is characterized by a person's ability to fulfil a number of key functions and activities, including: the ability to learn. the ability to feel, express and manage a range of positive and negative emotions. the ability to form and maintain good relationships with others. FACTS ABOUT SEVERAL PROMINENT DISORDERS Major Depressive Disorder Leading cause of disability in the United States Affects nearly twice as many women as men Schizophrenia Affects men and women equally; appears earlier in men Bipolar Affective Disorder Affects women and men equally Anxiety Disorder Frequently co-occurs with depressive disorders, eating disorders, and/or substance abuse Panic Disorder Typically develops in adolescence About 1 in 3 develops agoraphobia FACTS ABOUT SEVERAL PROMINENT DISORDERS Obsessive-Compulsive Disorder First symptoms begin in childhood or adolescence Generalized Anxiety Disorder Risk is highest between childhood and middle age Social Phobia Typically begins in childhood or adolescence MENTAL DISORDERS WITH STRONG BIOLOGICAL INFLUENCES Schizophrenia Bipolar disorder Major depression Obsessive-compulsive and panic disorders Posttraumatic stress disorder Autism Anorexia nervosa Attention deficit/hyperactivity disorder FACTORS THAT CAN AFFECT THE MENTAL HEALTH Other social conditions—such as interpersonal, family, and community dynamics, housing quality, social support, employment opportunities, and work and school conditions—can also influence mental health risk and outcomes, both positively and negatively (ODPHP, 2020) DYNAMIC FACTORS Mental illness is plagued by myths and misconceptions. No consistent line exists between mental illness and mental health. Psychiatry’s definition of mental health changes and reflects: - Changes in cultural norms and society’s expectations - Values and professional biases - Individual differences and political climate - At points in history, women who worked outside of the home and homosexuals were considered mentally ill DYNAMIC FACTORS All people: Have different backgrounds, cultures. Grow intellectually and emotionally at different rates. Make different decisions at different times. Choose to or choose not to evaluate their behaviors. Grow within themselves. Have or do not have spiritual beliefs. Understandably, then, no one definition of mental health exists that fits all. STIGMA AND MENTAL HEALTH Stigma is a negative stereotype that leads to an attitude or belief that would cause one to view a person with mental illness as inferior, dangerous, or unstable. Stigma has been acknowledged to be a major barrier to mental health treatment and recovery. Stigmatizing attitudes toward individuals who are mentally ill have harmful effects on the individual and family. Psychosocial processes that lead to stigmatization include: Stereotyping, labeling, separating, and status loss or discrimination in a context of power imbalance, social isolation, and reduced opportunities. COMPARE AND CONTRAST A DSM-5 DIAGNOSIS WITH A NURSING DIAGNOSIS. DSM-5 Mental disorders are clinically significant behavioral or psychological syndromes or patterns that occur in an individual and that are associated with distress, disability, or an increased risk of suffering death, pain, disability, or a loss of freedom or independence Classifies disorders that people have, not the person International Classification for Nursing Practice (ICNP) Allows nurses to identify nursing diagnoses and interventions COMPARE AND CONTRAST A DSM-5 DIAGNOSIS WITH A NURSING DIAGNOSIS. DSM-5 Nursing Diagnosis Schizophrenia Disturbed Thought Process Disease focused (pathophysiology) Patient focused (holistic approach) Criteria Related Factors: Altered perception, or Symptoms: auditory hallucination or disorganized thoughts biochemical alteration in the brain Evidence by disturbances in cognitive association or inappropriate verbalization CHAPTER 8 – THERAPEUTIC COMMUNICATION CHAPTER 8 – THERAPEUTIC COMMUNICATION Objectives 6. Identify four types of nontherapeutic communication and what makes them ineffective. 1. Described two theoretical models of communication 7. Relate problems that can arise when nurses are 2. Identify two personal, two environmental, and two relationship factors that can interfere with communication. 3. Discuss the differences between verbal and nonverval communication 4. Discuss verbal and nonverbal communication of different cultural groups in the areas of communication style, eye contact, and touch 5. Identify four techniques that can enhance communication, highlighting what makes them effective. insensitive to cultural influences on patients’ communication styles. 8. Discuss the increasing role of information communication technology in the delivery of healthcare, both in terms of advantages and concerns. 9. Summarize the best pace, setting, and seating arrangements for engaging in the nurse-patient interaction. 10. Identify two attending behaviors the nurse might focus on to increase communication skills 11. Described the importance of clinical supervision COMMUNICATION Just as social relationships are different from therapeutic relationships, basic communication is different from the professional, goal-directed, patient-centered and scientifically based communication we call therapeutic communication. COMPARE AND CONTRAST A SOCIAL RELATIONSHIP AND A THERAPEUTIC RELATIONSHIP Social Relationship Includes friendship and socialization. Mutual needs are met. May include giving advice. Basic needs are met. Content is superficial. Roles may shift. Little evaluation of interaction occurs. Therapeutic Relationship Nurse maximizes communication skills, understanding of human behaviors, and personal strengths to enhance patient’s growth. Patient needs are addressed. Language is straightforward. Focus is on the patient’s ideas. COMMUNICATION It is often in the psychiatric rotation that students discover the importance of communication and increase their ability to utilize “therapeutic communication” and begin to rely on techniques they once considered artificial. With continued practice, you will develop your own style and rhythm, and eventually these techniques will become a part of the way you communicate with others. Will saying the “wrong” thing be harmful to the patient? - Hardly, especially if your intent is honest, your approach is respectful, and you have a genuine concern for the patient. - Communication is up to 90% nonverbal, and surprisingly, most individuals pay attention to nonverbal cues such as what they perceive as your intent. ENVIRONMENTAL NOISE Physical noise Physiological noise Psychological noise FACTORS THAT AFFECT COMMUNICATION Personal factors can include: Emotional (mood, responses to stress, personal bias, relationship misunderstandings) Social factors (previous experiences, cultural differences, language difference and lifestyle difference) Cognitive factors (problem-solving ability, knowledge level and language) Environmental factors can include: Physical factors (background noise, lack of privacy, uncomfortable accommodations) Societal determinants (sociopolitical, historical or economic factors) COMMUNICATION Communication is about 10% verbal and 90% nonverbal Communication involves two symbols: Spoken word: Represents the public self. Can be straightforward comments or can be used to distort, conceal, deny, or disguise true feelings. Nonverbal behaviors: Any body gestures such as facial expressions, body posture, hand movement, etc. NONVERBAL Facial Expressions Tone of Voice Movement Appearance Eye Contact Gesture Posture EFFECTIVE COMMUNICATION SKILLS FOR NURSES Long term goals: - Identify and explore problems relating to others - Discover healthy ways of meeting emotional needs - Experience satisfying interpersonal relationships - Table 9.2 EFFECTIVE COMMUNICATION SKILLS FOR NURSES Active Listening ACTIVE LISTENING Observing the patient’s nonverbal behaviors Listening to and understanding the patient’s verbal message Listening to and understanding the person in the context of the social and cultural setting of his or her life Listening for “false notes” (i.e. inconsistencies or things the patient say that need more clarification) Providing the patient with feedback about himself or herself of which the patient might be unaware EFFECTIVE COMMUNICATION SKILLS FOR NURSES Use of Silence - Nurses who feel compelled to fill every void with words often do so because of their own anxiety, selfconsciousness, and embarrassment. - Allows patients to express one self THERAPEUTIC COMMUNICATION Some of the techniques to note - Restating - Attempting to translate into feelings - Exploring - Seeking clarification - Presupposition questions (The “Miracle Question”): What would you like to see change (if miracle occurred – goal setting) EFFECTIVE COMMUNICATION SKILLS FOR NURSES The goals of the nurse in the mental health setting are to help the patient: Feel understood and comfortable. Identify and explore problems relating to others. Discover healthy ways of meeting emotional needs. Experience satisfying interpersonal relationships. TECHNIQUES THAT CAN OBSTRUCT COMMUNICATION, HIGHLIGHTING WHAT MAKES THEM INEFFECTIVE. Giving premature advice Minimizing feelings Being falsely reassuring Making value judgments Asking “why” questions Asking excessive questions Giving approval; agreeing Giving disapproval; disagreeing Changing the subject HEALTH CARE PROFESSIONALS AND CULTURE Understand both verbal and nonverbal communication styles of diverse populations. Be aware of the cultural meanings of verbal and nonverbal communications to form positive therapeutic alliances. Attitudes and beliefs regarding diverse populations affect relationships with patients. EMPATHY, GENUINENESS, AND POSITIVE REGARD Empathy Is “temporarily living in the other’s life.” Empathy vs. sympathy In empathy, we understand the feelings of others. In sympathy, we feel the feelings of others; objectivity is lost. Genuineness Self-awareness of one’s feelings occurs; develops the ability to communicate when appropriate. Positive regard Displays respect; has the ability to view another person as worthy. INFLUENCE OF TRANSFERENCE AND COUNTERTRANSFERENCE CAN CAUSE BOUNDARY BLURRING Transference Person unconsciously and inappropriately displaces (transfers) those emotional reactions that originated from significant figures in childhood onto another individual. The patient may say, “You remind me of ___________.” Countertransference Tendency of the nurse to displace feelings related to people in his or her past onto a patient. Frequently, the patient’s transference to the nurse evokes countertransference feelings in the nurse.
