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

Click on the link below for a
video message from your
instructor.

http://www.screencast.com/t/7
2WMOeLbNzP

ATI Tutorial (Course Quiz #2)

Pharmacology Made Easy 2.0
 ID = TU1532398
 Password = 15F7U
 Module = The Neurological System (Part 2)
Here’s a Link to the ATI Website!
https://www.atitesting.com
•
Psychoanalysis / Psychotherapy / Behavioral Therapies
•
Group and Family Therapy
•
Stress Management
•
Electroconvulsive Therapy

Approaches to addressing mental health
issues using various methods and theoretical
bases

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

Psychodynamic Psychotherapy



Interpersonal Psychotherapy (IPT)



Same tools as Psychoanalysis But!....
Oriented more to client’s present state than early life
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.
▪

Behavioral Therapy






Used to treat depression / anxiety / eating disorders / other issues that require changing attitude toward life
experiences
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
Type
Modeling
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

Positive rewards for positive
behavior

Ex: tokens given for good behavior which can be
exchanged for a privilege or other items
Systematic Desensitization

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


Client masters relaxation techniques
Client exposed to increasing levels of anxietyproducing stimulus
Relaxation used to overcome anxiety
Client then able to tolerate greater and greater
level of stimulus



Aversion Therapy

Maladaptive behavior paired with a
punishment or unpleasant stimuli

Therapist uses unpleasant stimuli as punishment
for undesirable behaviors
o Bitter taste/mild electric shock
Medication / guided imagery/
diaphragmatic breathing /
muscle relaxation /
biofeedback

Techniques used to control pain /
tension / anxiety

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
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.
Cognitive Technique
B
The client discusses his dreams with the therapist.
Assertiveness Training
C
The client is encouraged to stop sucking his thumb by having a bitter liquid
applied to his thumb.
Aversion Therapy
D
A client who feels awkward in group social situations watches a video
showing some positive ways to interact in groups.
Modeling
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

Group Therapy Isn’t…

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
Healthy Families
Dysfunctional Families
Communication


Clear understandable messages between family members 
Each member encouraged to express individual feelings
and thoughts
Management




Adults of family agree on important issues
Rule-making
Finances
Plans for the future

Management may be chaotic
o
Child making management decisions at times
Boundaries




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
Socialization



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

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





One or more members use unhealthy patterns
o
Blaming
o
Manipulating
o
Placating
o
Distracting
Children do not learn health socialization skills within the
family
Have difficulty adapting to socialization roles in society
Negative emotions predominate most of the time
Members are isolated and afraid
o
Do not show concern for each other

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
Focus




Client needs and problems
The therapeutic relationship
Family needs and problems
Improving family
relationships
Goals






Group

Help individuals develop
functional and satisfying
relations within a group
setting


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
common feelings /
experiences / thoughts
o Experience positive behavior
changes as result of group
interaction and feedback

Structural family therapy example

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.
B.
C.
D.
Democratic
Laissez-faire
Autocratic
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.
B.
C.
D.
placation
manipulation
blaming
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”
Prolonged Stress
(maladaptive responses)
Apprehension
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 risk for myocardial infarction / stroke
Increased metabolism and glucose use
Poor diabetes control / hypertension / fatigue /
irritability / decreased ability to concentrate
Depressed immune system
Increased risk for infection

Life-Changing Events Questionnaires
 Holmes Rahe Stress Scale (see handout)
 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
Client Outcomes
▪
▪
▪
▪
▪




Meditation
Guided imagery
Breathing Exercises
Progressive Music Relaxation (PMR)
Physical Exercise
Journal Writing
Priority Restructuring
Biofeedback
Assertiveness Training
• Client will verbalize stressors and
ways to decrease exposure
• Client will demonstrate
appropriate relaxation
techniques
• 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.
b.
c.
d.
Weight loss
Apprehension
Fatigue
Insomnia

Electroconvulsive Therapy

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

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