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Chapter 56

Mental Health
Be Flexible
take responsibility for own actions
Form Close Relationships
Make Appropriate Judgments
Solve Problems
Cope with Daily Stress
Have a Positive Sense of Self
good to be close but you still need to know your boundaries

Mental Illness
Impairment of Ability to
Make Sound Judgments
Cope with Reality
Form Strong Personal Relationships
mental health and mental illness exist on a continuum.
natural for emotions to ebb and flow from day to day on the degree of stress.
people who are mentally healthy can cope and keep stress in perspective
others are not able to do so and overtime may develop physical or emotional illnesses
as a result of stress, past and present
people who have mental health difficulties cannot maintain proper homeostasis with the
amount of stress vs. how much stress they mentally can cope with.

Etiology of Mental Illness

Brain Dysfunction
it is important to note that while mental illnesses can be cate gorized as brain diseases,
not all brain diseases are mental illnesses.
Most mental illnesses have no identifiable cause
Environmental Factors
Theories of Mental Illness
it is important to ha ve an understanding of broad customs and beliefs to avoid
unrealistic expectations of patients.
Spirituality and Religion
necessary to be comfortable talking to the patient about spiritual needs while being
careful not to impose personal values on the patient.
If you are not comfortable in these situations, you should offer to call the
spiritual or religious leader of the patients choice.
Nursing Assessment
Appearance and Behavior
Level of Awareness and Reality Orientation
Thinking/Content of Thought
Speech/Communication 1344-1345
Mood and Affect
After data has been collected, th eLPN collaborates with the RN to develop nursing dx

Diagnostic Tests
A primary care provider may choose to refer a patient to a psychiatrist or other mental
health professional for further testing and diagnosis.
groups illnesses into categories of clinical disorders.
a complex diagnostic tool.
Although as an LPN you will not be responsible for completing the assessment or
making a diagnosis, you can contribute valuable information.
Age, hand tremors, vision, language barriers, educational background, and the
interpretation of the health care provider are some factors that can influence the results
of these tests.
Tests to Rule Physical Illness
Blood Work-can rule out problems such as electrolyte imbalances, hypothyroidism,
infections, dehydration, drug toxicity, or pregnancy
CT, MRI- can rule out tumors, lesions, or other physical problems
PET-can identify how the parts of the brain are functioning by showing chemical
activity or metabolism.
Psychological Tests

The Way One Adapts Psychologically, Physically, and Behaviorally to a Stressor
People have different methods of coping or dealing with their stressors.
Culture, religion, individual belief systems, experience, and personal choice influence a
persons responses to stress.
It is not the value of a behavior that we assess as nurses; it is the desired outcome that is
important.What is an effective coping skill? Is it healthy? Does it work? How do we as
nurses observe and measure it?
Effective Coping Skills:
conscious mechanisms
process of effective coping is sometimes called adaptation.
Allowing the patient to practice new coping techniques will give him or her confidence
and will decrease the stress that can accompany change.
mild anxiety can be positive.
when there is a little anxiety , people are more alert and ready to respond.
The fight- or-flight mechanism can actually help one adapt to a new situation.
too much anxiety can cloud the consciousness and interfere with the ability to make
appropriate choices and to recall new adaptive tools that have been learned
One of the most helpful roles you can perform is to listen to the patient s thoughts and
feelings about the stressor, assist him or her in identifying precipitating factors and
patterns to the patients stress, encourage the patient to problem solve, and provide
assistance to develop alternative solutions to a problem.
Ineffective Coping Skills
When conscious techniques are not successful, people may unconsciously fall into
habits that give the illusion of coping. These habits are called ego defense mechanisms
(or coping or mental mechanisms)
The purpose of ego defense mechanisms is to reduce or eliminate anxiety.
give the impression that they are helping alleviate the stress level.
when used in very small doses, ego defense mechanisms can be helpful.
when they are overused or are the only means used to deal with anxiety, they can
become ineffective and unhealthy.
not born with these coping behaviors
learned as responses to stress.
they develop by age 10

Ego Defense Mechanisms

Usually the first defense learned and used. Unconscious refusal to see reality; not
conscious lying.
The alcoholic states, I can quit any time I want to.
Repression (stuffing)
An unconscious burying or forgetting mechanism. Excludes or withholds from
consciousness events or situations that are unbearable.
A step deeper than denial. A patient may forget about an appointment he or
she does not want to keep.
Using a logical-sounding excuse to cover up true thoughts and feelings. The most
frequently used defense mechanism.
I made a medication error because the doctors orders were confusing.
I failed the test because the teacher wasnt clear about what would be on it.
Making up for something perceived as an inadequacy by developing some other
desirable trait.
The small boy who wants to be a basket- ball center instead becomes an honor
roll student.
The physically unattractive person who wants to model instead becomes a
famous designer.
Reaction Formation (overcompensation)
Similar to compensation, except the person usually develops the exact opposite trait.
The small boy who wants to be a basket- ball center becomes a political voice to
decrease the emphasis on sports in the elementary grades.
The physically unattractive person who wants to be a model speaks out for
eliminating beauty pageants.
Emotionally returning to an earlier time in life when the patient experienced far less
stress. Commonly seen in patients while hospitalized. NOTE: People do not go back
to the same developmental age. This is highly individualized.
Children who are toilet trained begin to wet the bed after the birth of a younger
Adults start crying and have a temper tantrum.
Ascribing ones own unacceptable qualities or feelings to someone else. May lead to
A patient might state: My sister is so jealous of me, when actually the patient
is jealous of her sister.
An anxious patient may say to the nurse, Why do I make you so nervous?
Displacement (transference)
Kick-the-dog syndrome. Transferring anger and hostility to another person or
object that is perceived to be less powerful than oneself.
Parent loses job without notice; goes home and verbally abuses spouse, who
unjustly punishes child, who slaps the dog.
Restitution (undoing)
Make amends for a behavior one thinks is unacceptable. Makes an attempt at
reducing guilt.
A person gives a treat to a child who is being punished for a wrongdoing.

The person who sees someone lose a wallet with a large amount of cash does not

return the wallet, but puts extra in the collection plate at the next church
Conversion Reaction
Anxiety is channeled into physical symptoms. Often the symptoms disappear soon
after the threat is over.
Nausea develops the night before a major exam, causing the person to miss the

exam. Nausea may disappear soon after the scheduled test is finished.
Unconsciously staying away from events or situations that might cause feelings of
aggression or anxiety.
I cant go to the class reunion tonight. Im just so tired, I have to sleep.
Therapeutic Communication
It is important to be intentional about the messages we communicate to patients.
Therapeutic communication is accomplished through the deliberate use of verbal and
nonverbal techniques.
Other areas to consider when communicating are the patients personal values,
attitudes, beliefs, culture, religion, social status, gender, and age or developmental level.
Verbal therapeutic communication techniques can help facilitate an interpersonal
Verbal communication is also influenced by the tone, pitch, speed, and volume of speech.
Avoid Communication Blocks

A nurse who tells a patient Dont worry, everything will be all right has just given the
patient false reassurance. This barrier communicates to the patient that his or her
concerns are not being taken seriously.

Therapeutic Measures
Therapeutic Milieu-therapeutic environment
It is believed that environment has an effect on behavior.
Milieu therapy is the systematic management of the social environment as a
treatment modality.
an environment that provides containment, support, structure, involvement, and
validation during the patient s stay.
goals of milieu therapy are resocialization, ego development, and prevention of
Re-socialization occurs when patients help govern the running of the unit and
attend regular meetings to set rules and assign tasks.
Ego development is fostered with structured activities that are provided to
assist the patient to learn coping and social skills.
Regression is discouraged when patients help with washing dishes or other
small jobs that foster independence.
Common milieu interventions include role modeling, positive reinforcement,
a schedule of events, consistent expectations and rules for behavior, and
unit meetings.
Milieu therapy is difficult in this era of managed care because of shorter
hospital stays.
the use of medications to treat psychological disorders.
Since the introduction of the phenothiazine class of drugs in the 1950s (e.g.,
chlorpromazine), the number of medications available for treating mental health
disorders has increased greatly, with newer medications having fewer side effects.
The reason for using medications is twofold:
First, the medications manage the symptoms, helping the patient feel more
comfortable emotionally .
Second, the patient is generally more receptive and able to focus on other types
of therapy if medications are effective.
the form of treatment chosen by the psychologist, psychiatrist, social worker, or
advanced practice mental health nurse.
The goals of psychotherapy include the following:
Reduce the patients emotional discomfort.
Increase the level of the patients social functioning.
Increase the ability of the patient to behave or perform in a manner appropriate
to the situation.
consists of clarifying the meaning of events, feelings, and behavior and thereby
gaining insight into them
developed from Sigmund Freud s psychoanalytic theory.
Freud believed that anxiety was the primary motivation for behavior and
therefore all behavior had meaning.
The role of the patient is to provide the therapist with clues to the unconscious
source of problems and to try to develop insights into behavior.
The role of the therapist is to uncover these unconscious experiences and interpret
their meanings to the patient.
Behavior Management
also called behavior modification
a treatment method that stems from the studies of behavioral theorists such as
Skinner and Pavlov.
a common treatment modality used in long-term care facilities, with children and
adolescents, and with individuals who have a low level of cognitive functioning.
According to behavior management theory, all behavior is learned, so it can be
The belief is that behavior can be changed by either positive or negative
Positive reinforcement is the act of rewarding the patient with something
pleasant when the desired behavior has been performed.
For instance, if a patient has the habit of using foul language in an attempt
to have a need met, the desired behavior change might be to come to a staff
member and ask appropriately for what he or she needs. If this patient
loves to be outside but is not allowed out except at supervised times, then a
suitable positive reinforcement for her might be to allow 15 more minutes
outdoors when the desired behavior is exhibited.
Negative reinforcement is the act of responding to the undesired behavior by
taking a way a privilege or adding a responsibility.
Negative reinforcement can be misinterpreted as punishment.
Parents who ground their children for unacceptable behavior are using
negative reinforcement;
requiring the child to perform extra household tasks for a stated period is
reinforcing the fact that the behavior has consequences.
The child may not repeat the undesired behavior after negative
reinforcement has been used.
It is necessary to be careful to avoid violating the Patients Bill of Rights
when performing behavior management with patients.
A signed consent from the patient is advised when using this form of
The patient must understand the consequences of the behavior to be
changed and the purpose for the type of consequence that is chosen.
**If the person is not capable of understanding the situation or is not
able to remember the consequences, behavior management may not be
the best form of treatment. **
Cognitive Behavioral Therapy
Cognitive behavioral therapists believe that people experience mental illness due to
cognitive distortions about their situations.
stresses ways of rethinking situations.
The therapist confronts the patient with certain distortions of thinking and then
works out ways of thinking about them differently.
This type of treatment is used frequently for affective or mood disorders.
Feeling sad about an unpleasant experience (such as the death of a loved one) is
acceptable and normal, but long-term depression about the death is an extreme
emotion and therefore considered to be unhealthy.
In this situation, the patient might be helped to see the death as a sad loss.
Behavioral techniques are also often used with phobias or panic disorders, in which
fear may interfere with reasoning.
are gaining in popularity since they are shorter term than other types of therapy
and therefore less costly to the patient.
Patients are given homework that is specific to their needs; they practice their
assignments between sessions.
in combination with medications can provide effective treatment for depression.
the provision of help or guidance by a health care professional.
You may be asked or expected to accompany patients to counseling sessions or
even to facilitate a group discussion.
Remember that these are confidential sessions, even if they are group
Patients are there to work; others are there by invitation for special
Group Therapy
they can be ongoing or short term depending on the needs of the patients or the type
of disorder .
cost effective means of providing treatment.
For example, Alcoholics Anonymous (AA) and similar 12-step self-help groups
are well-established, ongoing groups formed around treatment of a specific
Family counseling sessions may occur with individual therapists with a
specialty in the problem area for that family.
Marriage counseling may be done in a group with other couples.
Many times, peer counselors are used.
Therapists and counselors are tools, or facilitators, in the therapeutic process.
Patients must take the suggestions given by the therapist, try them, and see what
works for them.
You can help by reinforcing the good work patients do to learn to stay mentally
healthy and develop more effective life skills.
form of treatment that is used for severely depressed patients who have not
responded to psychotropic medications.
ECT passes an electric current through the brain to produce a tonic-clonic
(grandmal) seizure.
stimulates an increase in circulating levels of the neurotransmitters serotonin,
norepinephrine, and dopamine in the brain.
affects neurotransmitter activity much like antidepressant medications.
may be frightening to patients;
it is important for the nurse to provide education and information to the patient
and family.
is currently a safe and effective treatment for resistant depression.
takes place in the recovery room of an operating suite, where there is ready
access to emergency equipment.
Informed consent must be obtained by the physician.
About 30 minutes before the procedure, the patient is given a medication to
dry secretions and counteract stimulation of the vagus nerve, which can
cause bradycardia and syncope.
given a short-acting anesthetic before the treatment and a smooth muscle
relaxant to minimize injury.
Before giving the muscle relaxant, a blood pressure cuff is placed on one of
the patients lower limbs and inflated. This is to ensure that the seizure
activity can be visually monitored in this limb.
Blood pressure and pulse are carefully monitored before and after the
The patient is oxygenated with pure oxygen during and after the seizure
until spontaneous respirations return.
During treatment, an electrical stimulus is delivered to the brain via
unilateral orbilateral electrodes.
The amount of electrical energy used is individualized to the patient.
The seizure must last at least 30 seconds to be effective.
The seizure activity is monitored with an electroencephalogram (EEG)
and also in the cuffed limb.
Side Effects:
can be unpleasant but are usually temporary.
The patient may feel confused and forgetful immediately after the
This can be from a combination of the ECT itself and the
medication that was used before the treatment.
If the seizure was severe, the patient may have some muscle soreness.
ECT is not used indiscriminately.
It is used when other therapies have not been helpful and is
usually reserved for treatment-resistant depression
Nursing Care:
The patient should receive nothing by mouth (NPO) for at least 4 hours
before a treatment.
Remind the patient to empty his or her bladder and to remove dentures,
contact lenses, hairpins, and other items on the body.
Following ECT, carefully monitor vital signs and document the
patients subjective and objective responses to the treatment.
Stay with the patient until he or she is oriented and able to care for him
or herself.
Withhold oral medications and food until the gag reflex returns.
Ensure that the patient is kept safe after ECT therapy.
Relaxation Therapy
exercises such as deep, rhythmic breathing can increase oxygenation and provide
distraction from stressors.
Breathing exercises may be coupled with progressive muscle relaxation
patients are taught to start at the head and neck and systematically tense and
then relax muscle groups as they progress toward the lower extremities.
Soft music may enhance the patients ability to fully relax.
Imagery is the use of the imagination to promote relaxation.
For this technique, the patient is taught to imagine a pleasurable experience
from his or her past, such as lying on a beach or soaking in a warm bath.
Use of all senses is encouragedfor a beach image, the patient might see a
beach, feel the warm sun, smell salt air,
and hear w aves crashing against the
The patient might also be taught to
visualize being successful in a problem
Relaxation techniques may be used
individually, but they are often used in
combination with each other or with other
therapies for maximum effect.