4.2 Psychiatric-Mental Health Nursing & Behavioral Interventions
Key Takeaways
- Therapeutic communication techniques, such as active listening and reflecting, are essential; non-therapeutic techniques like giving advice or false reassurance should be avoided.
- In patients with severe depression, assessing for suicidal ideation (intent, plan, and means) is always the highest nursing priority.
- Schizophrenia is characterized by positive symptoms (hallucinations, delusions) and negative symptoms (flat affect, anhedonia).
- Lithium toxicity occurs at levels > 1.5 mEq/L; symptoms include coarse tremors, severe diarrhea, vomiting, and confusion.
- When a patient is experiencing acute mania, the priority is maintaining safety, reducing environmental stimuli, and providing high-calorie, portable finger foods.
Psychiatric-Mental Health Nursing
Psychiatric-mental health nursing involves the assessment, diagnosis, and treatment of individuals with psychiatric disorders. The core of this practice relies heavily on establishing a therapeutic nurse-patient relationship and utilizing evidence-based communication techniques to facilitate healing and behavioral change.
Therapeutic Communication
Therapeutic communication is goal-directed, patient-centered, and objective. On the MOH exam, prioritizing therapeutic responses is a common testing point.
Effective Techniques (Do's)
- Active Listening: Giving full attention, using eye contact, and nonverbal cues like nodding.
- Broad Openings: Allowing the patient to steer the conversation (e.g., "What would you like to talk about today?").
- Restating/Reflecting: Repeating the main idea expressed or directing questions/feelings back to the patient to encourage exploration (e.g., Patient: "I'm so angry at my brother." Nurse: "You are feeling angry with your brother.").
- Clarifying: Seeking to understand unclear statements (e.g., "I'm not sure I follow what you mean by...").
- Offering Self: Being present and available without conditions (e.g., "I will sit with you for a while.").
Non-Therapeutic Techniques (Don'ts)
- Giving Advice: Tells the patient what to do, taking away their autonomy (e.g., "I think you should leave your husband."). Alternative: Explore options with the patient.
- False Reassurance: Minimizes the patient's feelings and cuts off communication (e.g., "Everything will be fine.").
- Asking "Why" Questions: Can sound accusatory and make the patient defensive (e.g., "Why did you stop taking your medication?"). Alternative: "What happened that led you to stop taking your medication?"
- Minimizing Feelings: (e.g., "Everyone gets sad sometimes.")
Major Psychiatric Disorders
Depressive Disorders
Major Depressive Disorder (MDD) is characterized by a persistently depressed mood and loss of interest (anhedonia) lasting at least two weeks.
- Clinical Features: Weight changes, sleep disturbances (insomnia or hypersomnia), fatigue, feelings of worthlessness, impaired concentration, and recurrent thoughts of death or suicide.
- Nursing Priorities:
- Safety: Assessing suicide risk is always the #1 priority. Ask directly: "Are you thinking of harming yourself? Do you have a plan? Do you have the means?"
- Nutrition/Hydration: Monitor intake; offer small, frequent, high-calorie meals if intake is poor.
- Hygiene: Encourage and assist with ADLs as needed, promoting independence gradually.
Bipolar Disorders
Bipolar disorder involves extreme mood swings from mania (hyperactivity, euphoria, decreased need for sleep, grandiosity) to depression.
- Acute Mania Interventions:
- Safety/Milieu: Provide a quiet environment with low stimuli. Remove hazardous objects.
- Nutrition: Provide "finger foods" (e.g., sandwiches, protein bars, fruit) and high-calorie fluids that the patient can consume while pacing or moving around.
- Communication: Use short, concise, and firm statements. Set clear limits on inappropriate behavior.
- Sleep: Encourage rest periods and structure the day to promote sleep hygiene.
Schizophrenia Spectrum Disorders
Schizophrenia is a severe mental illness affecting thought processes, perception, and affect.
- Positive Symptoms (excesses/distortions):
- Hallucinations: False sensory perceptions (auditory are most common).
- Delusions: Fixed, false beliefs (e.g., paranoia, grandiosity).
- Disorganized Speech/Behavior: Word salad, echolalia (repeating words).
- Negative Symptoms (deficits):
- Flat Affect: Lack of emotional expression.
- Anhedonia: Inability to experience pleasure.
- Avolition: Lack of motivation or drive.
- Alogia: Poverty of speech.
- Nursing Interventions for Hallucinations/Delusions:
- Do not argue with the delusion or agree with it. Validate the feeling behind it (e.g., "I understand you are frightened by those voices, but I do not hear them.").
- Maintain reality orientation.
- Ensure safety if the patient is experiencing command hallucinations (voices telling them to harm self or others).
Psychopharmacology
Understanding common psychotropic medications, their side effects, and required monitoring is critical.
Antidepressants
- SSRIs (e.g., Fluoxetine, Sertraline, Citalopram): First-line treatment. Side effects include GI upset, sexual dysfunction, and weight gain. Risk of Serotonin Syndrome (agitation, fever, tachycardia, rigidity) if combined with other serotonergic agents.
- Tricyclic Antidepressants (TCAs) (e.g., Amitriptyline): Side effects include anticholinergic effects (dry mouth, blurred vision, constipation, urinary retention) and orthostatic hypotension. Lethal in overdose due to cardiac toxicity.
- MAOIs (e.g., Phenelzine): Rarely used due to severe food-drug interactions. Patients must adhere to a tyramine-free diet (avoid aged cheeses, cured meats, wine, pickled foods) to prevent a hypertensive crisis.
Important Note: Antidepressants carry a black box warning for increased risk of suicidal thoughts, particularly in children and young adults, especially during the first few weeks of therapy as energy improves before mood does.
Mood Stabilizers: Lithium
Used primarily for Bipolar Disorder.
- Therapeutic Range: Narrow therapeutic index (0.6 - 1.2 mEq/L).
- Toxicity: Levels > 1.5 mEq/L. Early signs include nausea, vomiting, diarrhea, coarse hand tremors, and confusion. Severe toxicity can lead to seizures and coma.
- Nursing Considerations: Patient must maintain consistent sodium intake (sodium depletion increases lithium retention, leading to toxicity) and adequate hydration (2-3 Liters/day). Monitor renal (BUN/Creatinine) and thyroid function.
Antipsychotics
Used for schizophrenia and acute mania.
- First-Generation (Typical) (e.g., Haloperidol, Chlorpromazine): Treat positive symptoms. High risk for Extrapyramidal Symptoms (EPS):
- Dystonia: Muscle spasms of neck/face.
- Akathisia: Restlessness, pacing.
- Pseudoparkinsonism: Shuffling gait, rigidity, tremors.
- Tardive Dyskinesia (TD): Involuntary movements of tongue/face (often irreversible).
- Second-Generation (Atypical) (e.g., Clozapine, Risperidone, Olanzapine): Treat both positive and negative symptoms. Lower risk of EPS, but higher risk for Metabolic Syndrome (weight gain, dyslipidemia, hyperglycemia).
- Special Note for Clozapine: Risk for Agranulocytosis (severe neutropenia). Requires strict monitoring of WBC and ANC (Absolute Neutrophil Count). Instruct patient to report any signs of infection (fever, sore throat) immediately.
- Neuroleptic Malignant Syndrome (NMS): A rare but life-threatening reaction to antipsychotics. Symptoms include high fever, severe muscle rigidity, altered mental status, and autonomic instability (fluctuating BP, tachycardia). Requires immediate discontinuation of the drug and intensive care.
A patient with major depressive disorder tells the nurse, "I don't see the point in going on. Things are never going to get better." Which of the following is the priority nursing response?
A patient taking lithium carbonate for bipolar disorder presents to the clinic with coarse hand tremors, vomiting, and confusion. Which action should the nurse take first?