Roles of the nurse in different treatment modalities

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Roles of the nurse in different treatment
modalities settings

• Chia-Ling Mao

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Individual Psychotherapy

• Foundation trusting relationship
• Goal changes in behaviors, self-perceptions,
  emotional comfort, insight
• Conceptual framework multiple including CBT
• Basic trust empathy helping the clients to
  help themselves empowerment with self-esteem
  self worth
• Transference
• Managed care -gthow gt why
• Practical problem insurers will not cover the
  costs

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Types of individual therapies

• Classic psychoanalysis unconsciousness, R
• Cognitive therapy how irrational thinking
• Behavioral therapy - reshaping
• Cognitive - behavioral therapy thought action
• Rational emotive therapy situation, irrational
  belief -gt behavior
• Choice therapy doing gt feeling
  self-responsibility self-discipline
• Brief, solution-focused therapy

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Outcome of psychoanalysis

• Insight into repressed conflicts
• Restructuring of the personality based on
  integration of repressed conflicts.

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Cognitive Therapy

• Theorist Aaron Beck (1979)
• Cognitive Triad the interaction of the clients
  negative view of self, the world, the future
• How to perceive an event gt the event itself
• Cognition the clients construction of his
  world
• Roles of the nurse trust relationships, goals,
  review feelings, note accomplishments
• Using voicing doubt in dealing with clients
  cognitive distortion

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Techniques of cognitive therapy

• Look for idiosyncratic meaning
• Question the evidence
• Reattribute
• De-catastrophize, Fantasize consequences
• Examine options and alternatives
• Weight advantages disadvantages
• Turn adversity to advantage
• Using thought stopping
• Use distraction

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Outcome of cognitive therapy

• Recognition of irrational thinking patterns
• Enhancement of functional responses

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Behavioral Therapy

• The concepts of behavior therapy stimulus,
  response, reinforcement
• Behaviors are measurable, observable,
• Classical conditioning S -gt R
• Operant conditioning
• Discriminative stimulus, response, reinforcing
  stimulus
• Learning, extinction
• Identify techniques for increasing/ decreasing a
  behavior

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Behavior modification

• Conditioning
• Shaping
• Extinction
• Negative consequence
• Time out
• Reinforcement
• Modeling
• Token economy

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Nursing process behavior therapy

• Assessment appropriate/inappropriate behaviors,
  time, frequency, duration
• Dx expected changes
• Plan target response, decreasing or increasing,
  new skills
• Intervention reinforcement () (-)
• Evaluation outcomes (as planned) maintaining,
  additional change (if needed),

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Focus outcome of behavioral therapy

• Promotion of desirable behaviors with
  alternations of undesirable behaviors
• Reshaping of behavior with elimination of
  negative behaviors

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Cognitive-Behavioral Therapy

• Focus on making changes in current ways of
  thinking and behavior
• Nursing intervention self-responsibility
  self-discipline
• Nurse acting as a coach, teacher in identifying
  of situations involving undesirable thoughts and
  actions
• Example
• Pt My wife makes me so angry
• N What is self-defeating about the statement
  you just made

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Outcome of cognitive-behavioral TH

• Participatory relationship between client and the
  therapist
• Results oriented
• Client learning new skills

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Rational-emotive therapy (RET)

• Theorist Albert Ellis (1973)
• Present perceptions, thoughts, assumptions,
  beliefs, values, attitudes, and philosophies as
  needing modification or change.
• Should, ought, must .
• ABC theory Intervention is aimed at B
• A activating event
• B belief about A
• C emotional reaction
• Irrational belief -gt negative emotions

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Roles of the nurse in RET

• Acceptance do not allow the pt to condemn
  themselves
• Challenge/confront the irrational thinking
• Present centered
• Help the pt learn to take responsibility for
  their ideas and behaviors.
• Homework assignments focus on positive statements
  and behaviors and skill development
• Role-playing modeling

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Outcome of RET

• Client control of behavior and thinking
• Assumption of responsibility and blame for
  irrational beliefs

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Group Therapy

• Definition evolution
• Leadership
• Types autocratic, democratic, Laissez-faire
• power
• Group roles
• Group task roles initiator, information seeker,
  information giver, coordinator, recorder
• Group building maintenance roles encourager,
  harmonizer, gatekeeper
• Individual roles aggressor, blocker, recognition
  seeker, play person,

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Group dynamics

• Group content
• Group process
• Pre-interaction phase selecting members,
  contract
• Orientation phase searching for similarity,
  building norms, politeness,
• Working phase attempt to solve the problems,
  conflict, cooperation
• Termination phase evaluates the experience and
  explores members feelings about it and the
  impending separation

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Therapeutic factors of group therapy

• Instillation of hope
• Universality
• Imparting of information
• Altruism
• Corrective recapitulation of the primary family
  group
• Development of socializing techniques
• Imitative behavior
• Interpersonal learning
• Group cohesiveness
• Catharsis expression of deep emotions
• Existential factors

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Leadership style

• Democratic
• Autocratic
• Laissez-fairs

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Roles of the group member

• Group maintenance role
• Individual roles
• Blocker
• Dominator
• Follower
• Gatekeeper

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Family Therapy

• Background and evolution
• Family burden
• Iatrogenic burden from the MH
  system/professionals
• Objective burden practical problems
• Subjective burden grief, fear, guilt, anger

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Roles of the healthy family

• Responding to family members needs
• Coping actively with lifes problems and stressed
• Accomplishing family tasks with equal
  distribution of power
• Encouraging interaction among family members and
  the community
• Promoting positive personal health practices

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Conceptual framework of family therapy

• Structural family therapy Minuchin
• Boundary, role, sub-system conflicts are
  resolved in a rational manner
• Communication theory Satir
• Identified patient
• Communication style
• Distractor, placator, blamer,
• Pseudomutuality, pseudohostility
• System theory Bowen
• Calgary Family Assessment Model -

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Concepts in Bowens theory

• Differentiation
• Triangulation
• Nuclear family emotion system
• Family projection process
• Emotional cutoff
• Mutigenerational transmission process
• Sibling position

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Family Assessment Calgary Family Assessment
Model

• Family structure genogram, ecomap
• Family development/life cycle associated tasks
• Beginning families
• Early childbearing families
• Families with preschool children
• Families with school children
• Families with teenagers
• Launching center families
• Families of middle years
• Families in retirement and old age
• Family function
• Cultural consideration

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Nursing Diagnoses (FT)

• Altered family processes
• Ineffective family coping
• Impaired home maintenance management
• Related issues
• Concept of resilience
• Major concerns of the care giver?
• Resources NAMI
• Confidentiality can be a barrier to including
  families in care

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Conclusion on Family Therapy

• Family as a system
• Changes involve whole system
• Application of change theory (Prochaska, 1992)
• Precontemplation, contemplation, preparation,
  action, maintenance
• Family myths
• Family harmony
• Parental determinism
• Breakdown of the family
• Materialism

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Forensic Nursing

• Background overlap between the criminal justice
  mental health systems criminalization
  deinstitutionalization
• Clients victims, perpetrators, and their
  families
• Related issues legal, ethical, political,
  administrative, professional

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Characteristics of the forensic setting

• Physical setting
• Client population
• Authoritarian interpersonal environment

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Characteristics of the forensic population

• Poor judgment, limited reasoning abilities,
  history of not learning form past mistakes,
• High level of substance abuse
• Depression, suicidal ideation, aggressiveness,
  irritability, violence
• Personality disorder chr mental illnesses,
  mental retardation, brain injuries,
• Decreased social skills or physical strength
• Criminalized lifestyle

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Crisis Intervention

• Characters of crisis
• a threat to homeostasis -gt anxiety, confusion,
  loss of problem solving ability
• Crisis danger opportunity
• Short 4-6 weeks

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Phases of a crisis

• Increased anxiety -gt coping
• Coping failed -gt further increased anxiety
• Escalated anxiety -gt reach out for help
• Active state of crisis

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Balancing factors

• Realistic perception of the events
• Coping skills
• Support systems

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Nursing diagnoses

• Ineffective coping
• Anxiety
• Disturbed thought processes
• Situational low self-esteem
• Social isolation
• Impaired social interaction

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Types of crises

• Maturational or developmental crisis various
  task in different states
• Situational crisis - sudden traumatic event ie
  job loss
• Adventitious crisis precipitated by an
  unexpected event ie, natural disasters

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Somatic Therapy
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Electroconvulsive Therapy

• Historic background 1938
• Mechanism unknown
• Modern ECT
• Nursing care before ECT like before surgery
• Explanation fear, stigma, fear, anxiety
• Physical exam - vital signs, lab data, spinal
  X-ray
• Consent form preparation
• NPO for 8 hours, moveable accessory,
• Atropine
• Empty bladder

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Nursing care

• During ECT typical grand mal seizure with tonic
  and clonic phases
• After ECT
• Respiratory problems apnea, oxygen
• Confusion disorientation
• Memory impairment
• Recording

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Issues related to ECT

• Advantages - , safety, effect,
• Disadvantages memory impairment

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Community Care
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Objectives

• Review revolution of community mental health
• Define community support system
• Identify the levels of prevention on MI
• Describe roles of the nurse in community mental
  health care

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Landmarks in community mental health

• 1946 - Natl M H Act 1949- NIMN
• 1955 MH Study Act
• 60s - Community Mental Health Centers Act
• Deinstitutionalization
• 70s - Community Support Program
• case managers
• 80s Mental Health Systems Act
• 90s American Disabilities Act pts rights
• 2000 Healthy people 2010 NAMI NAMP
• National health goal advocacy

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Healthy People 2010

• 18-1. Reduce the suicide rate.
• 18-2. Reduce the rate of suicide attempts by
  adolescents
• 18-3. Reduce the proportion of homeless adults
  who have serious mental illness (SMI).
• 18-4. Increase the proportion of persons with
  serious mental illness (SMI) who are employed.
• 18-5. (Developmental) Reduce the relapse rates
  for persons with eating disorders, including
  anorexia nervosa and bulimia nervosa.

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Healthy People 2010 (contd)

• 18-6. (Developmental) Increase the number of
  persons seen in primary health care who receive
  mental health screening and assessment.
• 18-7. (Developmental) Increase the proportion
  of children with mental health problems who
  receive treatment.
• 18-8. (Developmental) Increase the proportion
  of juvenile justice facilities that screen new
  admissions for mental health problems.

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Healthy People 2010 (contd)

• 18-9. Increase the proportion of adults with
  mental disorders ( serious mental illness,
  depression, schizophrenia, generalized anxiety
  disorder) who receive treatment.
• 18-10. co-occurring substance abuse and mental
  disorders
• 18-11. community-based jail diversion programs
  for adults with serious mental illness (SMI).
• 18-12. track consumers satisfaction with the
  mental health services they receive.

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Healthy People 2010 (contd)

• 18-13. operational mental health plan that
  addresses cultural competence.
• 18-14. operational mental health plan that
  addresses mental health crisis interventions,
  ongoing screening, and treatment services for
  elderly persons.

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Community Support System

• A network of caring and responsible people
  committed to assisting a vulnerable
  population to meet its needs and develop
  its potential without becoming
  unnecessarily isolated or excluded from
  the community.

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Goals of community support system

• Improve the competence of the client
• Alleviate the symptoms
• Use various therapeutic constructs
• Improve outcomes
• Install hope
• Active participation in the rehab.
• Develop individual skills

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Levels of Prevention

• Primary prevention
• Health promotion continued well-being
• Disease prevention no potential threat
• Secondary prevention
• Screening, referral, crisis intervention
• Tertiary prevention
• Rehabilitation social skill training, self-help
  groups,

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Components of a Community Support System

• Availability adequate resources
• Accessibility outreach, 24 hours services
• Integration collaboration sharing
• Continuity inpt -gt rehab.
• Community involvement community resources,
  grass root work, empowerment, advocacy,

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Elements of Case Management

• Psychiatric rehabilitation
• Resource linkage,
• Consultation/ liaison
• Advocacy
• Crisis intervention
• Home care -gt improved functional ability
• Therapies

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Range of Community-based Care

• Home care - homebound clients
• Outreach services - for homeless clients
• Residential services -
• Group homes - temp./permanent housing
• Halfway house - chemical dependency
• Apartment living programs
• Foster care and boarding homes
• Self-help groups

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Numbers r/t Community Mentally ill

• In the U.S. 20 of adults MI
• 12 of children mental or emotional pro.
• 1/3 of homeless have serious MI gt1/2 have a
  substance abuse problem
• 7 of inmates have a serious MI 12.4 require
  psy attention
• 25 of those who have MI receive Tx.
• Many HIV infection or AIDS cases need psy Tx.

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Issues r/t community care

• Concepts about MI ie rehabilitation
• Stalled resources ie funding and planning
• Poverty ie. SSI
• Reinstitutionalization hosp jail
• Special education for disabled children
• Stigma employment, housing, self-esteem
• Reforms

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Application of Nursing Process

• Assessment
• Aggregates and problems bureau of census, vital
  statistics, survey, local news
• Individuals -Severity of individuals illness
  Amount of supervision required by the individual
• Diagnosis community oriented

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Nursing Process (contd)

• Planning
• Multidisciplinary team includes key people and
  agencies
• Short- and long-term goals
• Implementation
• Primary, secondary, tertiary preventions
• Evaluation
• On going process

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Home care

• Def- Part of a comprehensive health and mental
  healthcare system that aims to provide an array
  of health-related services to clients and
  families in their places of residence.
• Residence private home, residential care
  facilities, group homes,

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Characteristics of home care

• natural setting
• not an alternative to institutional care
• reduce or prevent hospitalization
• cost-effective
• rapidly growing and changing fields in health
  care, even though it is one of the oldest forms
  of ambulatory healthcare
• crisis intervention emergency response

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Goals of home care

• Teaching problem-solving, stress-reduction, and
  coping skills to the clients/family members/
  caregivers
• Providing respite and community resources
• Educating about MI/MH, medications, relapse
  prevention, and IPR communication skills
• Coordinating medical, social, spiritual,
  community based services

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Care for the homeless with MI

• 5 of the people with MI are homeless
• Co-morbidity ie DM, Respiratory infections,
  asthma, malnutrition, dental caries, STD, thyroid
  problems, foot problems

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Roles of nurse in caring for the homeless

• Knowledge no standard protocols
• Perform an assessment physical, mental status,
  violence, hopelessness, spiritual, substance
  abuse,
• IPR communication
• Immediate needs of the client
• Community resources

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Challenges

• Use traditional knowledge/skill in new setting
• Overlapping of professional and personal
  boundaries
• Short, crisis oriented inpatient stay
• Intensive outpatient services
• Wider range of treatment modalities
• Multidisciplinary collaboration

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Spirituality religion

• Spirituality
• A persons experience of, or a belief in, a power
  apart from his/her own existence an individual
  search for meaning
• The concept of ones relationship with a
  transcendent reality
• Religion
• Outward practice of a spiritual system of
  beliefs, values, codes of conduct, and rituals

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Significance of spirituality religion

• Social support -gt lower distress
• Better coping with physical illness
• Healthier lifestyle lower incidence of substance
  abuse with purpose in life
• Decreased level of depression, anxiety with
  higher life satisfaction

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Roles of the nurse

• Clarifying values - What people believe and what
  is important to them
• Involving interdisciplinary team
• Ethical concerns
• Do not abuse the professional status
• Do not misrepresent the state of the research
• Do not impose ones own values on clients

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Culture

• A set of standard for behavior which a group of
  people attribute to those around them and which
  they used to orient their own behavior
• A design for living, influences every aspect of
  human interaction

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Essential Features of Culture

• Culture is learned
• Culture refers to systems of meanings
• Culture acts as a shaping template
• Culture is taught and reproduced
• Culture exists in a constant state of change
• Culture includes patterns of both subjective and
  objective components of human behavior

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Other Cultural Domains

• Folk beliefs/religion - can be confused with
  religiosity
• Stereotyping labels - avoid generalizations
• Ethnopharmacology - genetic influence, effect,
  metabolism
• Herbal therapies - interactions with meds
• Folk healers tx approaches, e.g.., hysteria,
  psychosis

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Impact of Cultural Competency

• More successful patient education
• Increases in pts health care seeking behavior
• More appropriate testing and screening
• Fewer diagnostic errors.
• Avoidance of drug complications
• Greater adherence to medical advice
• Expanded choices and access to high-quality
  clinicians.

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Implications for Mental Health Care

• It provides guidelines for judgment of
  normality versus abnormality of behavior.
• It provides a proper understanding of human
  beings, whether their behavior is normative or
  deviant.

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Ethics

• Character, manners, moral, doing good
• Knowledge value reasoning
• Theories
• Altruism love others over oneself
• Egoism individual first
• Hedonism pleasure over all other values
• Rational paternalisms -
• Relativism subjectivism each culture /or
  individual decides what is right or wrong

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Basic Theories

• Utilitarianism goal-based
• the greatest happiness for the greatest number
• Deontology duty based, love-based
• Autonomy human right self-determination
• Beneficence do good
• Justice - fairness
• Non-maleficence do no harm
• Veracity telling the truth
• Fidelity - keeping promise

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Related to Culture

• Language communication
• Value decision maker
• Knowledge bill of rights

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Roles of the nurse

• Nurse Practice Act defines the scope and limit
  of nursing practice
• Nurses fundamental responsibility- value,
  concern, goals
• Ethics of caring (everyday ethics) respect,
  empathy, nurturing, commitment, being an advocate
• Participation of the family in decision making
  social assessment

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Alternative complementary therapy

• Definition healthcare practice not considered
  conventional by Western medicine.

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Alternative Therapies

• Background
• Evolution
• Significance
• lt ½ disclose their use of alternative therapies
• Side effect of alternative therapies
• Cultural competent nursing

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Introduction

• Alternative Therapies
• Long history
• Varieties
• Complementary Therapies
• Strength
• Body-mind-spiritual needs holistic principles
• Weakness
• Physiological functioning
• Interaction with prescribed medication

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Classification of Alt. Th

• Alternative systems of medical practice
• Traditional Chinese medicine acupuncture,
  ayurveda, naturopathy, homeopahty
• Mind-body intervention
• Meditation, imagery, music therapy, spiritual
  healing prayer
• Biologically based therapies
• Herbal therapies, aromatherapy
• Manipulative body-based methods
• Tai Chi, yoga, massage, chiropractice
• Energy therapies
• Reoolo, healing tough and therapeutic touch

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Roles of the nurse

• Respect the clients decision based on their
  health belief
• Review various modalities, and ask the client
  which he/she thinks will help.
• Collaboration among interdisciplinary team
  members

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Good luck with the test have a nice weekend