Assignment-

learning outcomes After this session you will have a better grasp of:

• theoretical approach used in MH nursing

• MH service and disorders overview

• MH nursing assessment overview

• factors impacting on the following disorders and description of the disorders

• psychosis-disorders where altered perception features • schizophrenia spectrum disorders-clinical features • neuro-cognitive [organic] disorders exhibiting psychosis

• client needs and nursing care/interventions

NURSING APPROACHES

• use a humanistic theory/approach

• also use sociological theories

• nursing is based on interpersonal relationship between the nurse and the client

• nursing seeks solutions for identified needs with the client

• but we work in environments dominated by the biomedical model and chemical treatments

conceptual overview-MH and related services

*In-patient

*Forensic Mental Health

*Community

*Alcohol Tobacco & Other Drugs Service [ATODS]

*CYMHS-Child & Youth Mental Health Services

*Non-Government Organisations [NGOs]

**Services for aged care, drugs including alcohol, & intellectual disability usually separate to MHS

5

new classification in the DSM V

Bipolar and related disorders are separated from the depressive disorders

in DSM-5 and placed between the chapters on

schizophrenia spectrum and other psychotic

disorders and depressive disorders in recognition

of their place as a bridge between the two diagnostic

classes in terms of symptomatology, family history,

and genetics.

quoted from Psychiatry online

6

some major disorders

• schizophrenias

• bipolar disorders

• depressive disorders

• personality disorders

• anxiety disorders

• obsessive compulsive and related disorders

• eating disorders

• substance related and addiction disorders

• childhood disorders e.g. ASD; ADHD

• neuro-cognitive: biological disorders [dementias, neurological, trauma, toxicity etc.]

Neurocognitive [organic] Disorders NCD

• cognitive decline [from mild to major] from a previous level of performance

in one or more cognitive domains

• deliriums

• dementias e.g. Alzheimer’s disease

• as a result of • Parkinson's Disease • drug intoxication/poisoning/other toxicity • vascular dementia • Acquired Brain Injury • systemic issues [e.g. infections]

• meningitis, encephalitis, thyroid-toxicosis, • renal failure and electrolyte imbalance 8

• the term, ‘psychosis’ simply means ‘out of touch with reality’ due to impaired perceptual, emotional, cognitive processes

• psychosis is not limited to disorders such as schizophrenia spectrum disorders or bipolar disorder

• psychosis can be associated with neurocognitive [organic]disorders

• symptoms may look very much like one of the major mental illnesses but are due to a bodily illness

psychosis and neurocognitive disorders

How common is psychoses?

In 2011 nationally almost 44,000 people with psychotic disorders receive services from public specialised mental health services in a one-month period.

Three-fifths (60.7%) are male and a similar proportion (60.8% or 26,625 persons) are in the older age group (35-64 years of age).

The overall prevalence is 4.5 cases per 1,000 population. (http://health.gov.au/internet/publications/publishing.nsf/Conte nt/mental-pubs-p-psych10-toc~mental-pubs-p-psych10-2)

possible psychosocial factors in many disorders

• social isolation

• situational difficulties

• trauma/abuse/bullying/neglect

• co-morbidity-drugs including alcohol

possible physiological factors

• biochemical

• nutritional deficits

• neuroendocrine disturbances (e.g. hypo/hyperthyroidism)

• genetic

• medication side effects

• other physiological conditions

mental disorders that may include psychoses

� schizophrenia

� schizophreniform psychoses

� schizo-affective disorder

� delusional disorder

� bipolar disorder(MDP)

� major depressive disorder

� brief psychotic episode, e.g. puerperal psychosis

a complex spectrum of disorders characterised by:

• loss of contact with reality • fragmented thoughts • perceptual disturbances • difficulties in processing information • inability to sort and interpret stimuli and select appropriate

responses

And problems in:

• managing emotions • making decisions • relating to others

what is schizophrenia?

• prevalence (the number of sufferers at a given time) in Australia: 1 in 100 people

• age of onset: 16 – 45 years (median 32 years)

• males: 16 – 20 years (earlier onset, more serious, worse outcome)

• females: 20 – 30 years

More Information SANE Australia: http://wwwsaneorg/information/factsheets-podcasts/187-schizophrenia

prevalence of schizophrenia

schizophrenia DOES NOT means a person has a split mind or personality-it is just the literal translation of the word

• one of most pervasive myths of schizophrenia

• the ‘split’ is with shared reality, not within the personality

misconceptions of schizophrenia

schizophrenia can be a chronic deteriorating illness…

but about 85% of individuals with a first episode of psychosis will recover

many will return to their prior level of functioning

misconceptions of schizophrenia

violence and schizophrenia

• most violent crimes are not committed by people with schizophrenia, and most people with schizophrenia do not commit violent crimes

• however the research evidence is mixed

For an overview of this study go to http://onlinelibrary.wiley.com/doi/10.1034/j.1600 -0447.2000.00012.x/full

recovery • living with dignity and personal meaning

• living a satisfying life

• hope for a better future

• self-responsibility

• empowered – achieving goals and autonomy

• self-respect and self-efficacy based on the person’s strengths

• choices and self-direction in treatment and social services

predictors of recovery

• supportive family or caregivers

• absence of substance abuse

• shorter duration of untreated psychosis

• good initial response to medication

• adherence to treatment

• a collaborative therapeutic alliance

• sound premorbid history

• access to continuous, comprehensive, consumer- orientated and coordinated care and treatment

symptoms of psychoses in schizophrenia and in neurocognitive [organic] disorders

symptoms of schizophrenia

symptoms are categorised as

either positive (Type I)

or

negative (Type II)

Positive (Type I) refers to disturbing symptoms/experiences that don’t occur in ordinary consciousness i.e. they are added >>>+ve [positive]

Negative (Type II) refers to the loss of certain characteristics that do occur in ordinary consciousness. i.e. they are lost>>>-ve [negative]

symptoms of schizophrenia

Ty pe

I P

os iti

ve S

ym pt

om s

Hallucinations Delusions

Thought disorder Acute Good

Absent

1

Response to anti-psychotics Intellectual impairment Ty

pe II

N eg

at iv

e S

ym pt

om s

Affective flattening Poverty of speech Loss of drive Chronic Poor Sometimes present

Type I Type II

Psychosis: signs and symptoms

although a separate category in the MSE, speech and thought disorders are closely related since any disorder in thought is demonstrated by disorders of speech

disorders in form of speech

disorders in content of speech and content of thought

disorders of thought form

perceptual disturbances

affect

behaviour

cognitive functioning

Disorder in speech content [reflects thought content] suicidal ideation

delusions:-

• fixed false beliefs that are inconsistent with a person’s cultural, social and religious beliefs and which cannot be changed by presentation of evidence or rational argument

types of delusions

persecutory\paranoid delusion: belief that one is being harmed, obstructed

nihilistic delusion: belief that one is dead

grandiose delusion: beliefs about one’s identity or status

somatic delusion: beliefs about bodily appearance, sensations, or functioning

erotomanic delusion: belief that another person is in love with them

bizarre delusions: delusions where the claim is not even vaguely possible

thought insertion/withdrawal/broadcasting; ideas of reference

Form of speech

Assess:

•volume • rate e.g. pressure of speech •tone e.g. monotonous

other disorders of speech form related to disorders of thought form >>>>see next slide

Formal thought disorder: disorder of thought form discerned from the person's speech

• loosening of associations/derailment-switching topics

• tangentially-move to a vaguely related or unrelated topic

• clang associations-new, blue, shoe, shoe

• word salad-incoherent

• thought blocking-thoughts blocked-sudden halt in speech

• neologisms-new words

• poverty of thought-little content

• echolalia-copies what you say

• perseveration –constant repetition of a phrase

• http://frontierpsychiatrist.co.uk/formal- thought-disorder/

• example of disorganised thought as a result of a formal thought disorder

• the name of this formal thought disorder is: loosening of associations

• can occur in bipolar, schizophrenia and other psychotic disorders

• formal thought disorder evident in speech/written language and behaviour

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Perceptual disturbances

Perceptual disturbance-inability to test and evaluate (shared) reality

• hallucinations - disturbance of sense perception with no external stimuli

• illusions – misinterpretation of external stimuli

mood, affect and related negative symptoms

less emotional expression -in the face, eye contact, intonation of

speech and movements of the hand, head, and face that usually give

speech its emotional tone

avolition –loss of will related to loss of motivation

alogia –reduced speech output

anhedonia –lack of pleasure in activities usually found pleasant and in

remembering previous good experiences

asociality –loss of interest in social interactions

behaviour

• disordered or bizarre behaviour [e.g. catatonia; posturing; regression]

• laughing for no apparent reason

• apparent talking to self or yelling as if to someone

• excessive writing, walking

• staring, grimacing, childlike ‘silliness’

• agitation/over excitement

Catatonia: disturbance of behaviour and movement

Cognitive and executive functioning

Disturbed:

• orientation to time, place and person

• abstraction-inability to discern meanings of metaphors calculations

Attention � difficulty in paying attention � poor concentration � distractibility � difficulty in selective attention

Memory � impaired ability to retrieve or

used stored � impairment in STM

Executive Functioning � indecisiveness � difficulty initiating tasks � impaired judgment � lack of insight � illogical thinking � lack of planning and problem

solving � impaired abstract thinking

Impact of Core Symptoms on Overall Functioning

Social Occupational

Work

Self-care

Interpersonal

Positive symptoms

Delusions Hallucinations Disorganised speech Catatonia

Negative symptoms Affect flat Alogia Avolition Anhedonia

Mood symptoms

Dysphoria Suicidality Hopelessness

Cognitive symptoms

Attention Memory Executive

function

Overall impacts

personality disintegration

diminished usual functioning

impaired judgment

regulation and control of drives and impulses

insight-nil or impaired

early warning signs of schizophrenia

ADLs

• deterioration of personal

care/hygiene/ eccentric dress

• excessive

fatigue/sleepiness/inability to sleep

• dropping out of activities

• decline in academic/athletic/work

performance

Social Issues

• withdrawal/isolation/reclusiveness

• deterioration of social

relationships

• Inability to concentrate/cope with

minor problems

• Conversation that seems deep,

but is not logical or coherent

• Inability to express emotion

early w arning signs of schizophrenia: behaviour/speech/cognition

• apparent indifference to im

portant

situations

• loss of w

ill and m otivation

• frequent m

oves or trips or long

w alks leading now

here

• drug or alcohol abuse

• inappropriate laughter

• strange posturing

• low

tolerance to irritation

• staring/vagueness

• unusual sensitivity to stim

uli (noise,

light, etc.)

• forgetfulness

• bizarre behaviour

• undue preoccupation w

ith

spiritual/religious m atters

• excessive w

riting w ithout apparent

m eaning

• irrational statem

ents

• peculiar use of w

ords or language

structure

• degree of insight can fluctuate

• lack of insight is not an inevitable

• m

any people rem ain aw

are of their dysfunction and are later able to recall details of the illness, external stressors and coping strategies

insight and schizophrenia

Q U

T library catalogue nam

e: C hanging m

inds the Inside story

C ase study

A nthony: [involuntary adm

ission]

exam ple of religious, grandiose and bizarre delusions

+ auditory and tactile hallucinations, lack of insight, danger of harm to self

and others

assessm ent of sym

ptom atology: the 5 dom

ains

• m

ood/affect

• com

m unication

• behaviour

• cognition

• physiology/bodily function

im pairm

ent interferes w ith a range of daily living activities

assessment

the 5 personal domains +

socio cultural context

• living arrangements

• family situation

• work/study issues

• legal issues

• spiritual issues or issues of meaning

note spiritual can but does not necessarily = religion

assess what the issues mean for the client-how do they interpret them?

• full organic screen to eliminate bodily illness

• preserve safety for self and others

• symptom reduction-medication is the first line treatment in Australia during the acute phase

• bio-psycho-social interventions achieve the best outcomes in a first episode psychosis

• complemented by a supportive, low-stress, non-stimulating environment

• develop a management plan

acute phase psychosis

principles of nursing care: therapeutic relationship and cultural safety

• undertake reflection for cultural safety

• recovery model-strengths based approach

• create therapeutic alliance

• establish

• show interest in and have time to spend

• listen to their story

• individualised care

• acknowledge the person’s feelings/story- “sounds like you are feeling at the end of

your tether” / “you’ve had a really difficult time”

• give feedback & don’t trivialise the person’s experience

• be highly observant and alert to clues about how the person is feeling

care based on thorough and on-going nursing assessment

collect information *history of presenting complaint * personal [biopsychosocial] history *family, living, school, legal, medical, psychiatric, AOD, * MSE &ongoing assessment

organise information *The 5 PPPs>>>> understanding >>>clinical formulation>>> Why this person, at this time, with this disorder?

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the role of nursing-part of MDT

• from assessment identify clients’ needs

• nursing aspects of medication

• observe & document major signs and symptoms

• diagnosis made on the basis of duration, intensity and clustering of signs and symptoms

• aim to limit impact of the disorder

• facilitate recovery based on strengths, hope, purpose, meaning

• growth beyond the disorder

common issues in nursing care

impaired or altered:-

• nutrition, elimination, sleep pattern, activity

• self-care deficits

• verbal communication

• social interaction/social isolation

• activity levels/types

• judgement

• insight

• risk for injury/suicide

• low self-esteem

• powerlessness

• disturbed thought processes

• disturbed sensory perception

thinking like a nurse- work with the client to prioritise needs

• assist to structure the day

• encourage and facilitate expression of feelings

• encourage social interaction

• positives/praise to encourage feeling of accomplishment

• explain legal status if voluntary or involuntary

• educate and support the client and family

• cognitive restructuring-techniques to explore and challenge negative/catastrophic thinking

• monitor wanted and unwanted effects of medication

nursing care

• sleep, nutrition, hydration, elimination, hygiene

• hallucinations

• delusions

• disorganised thinking and speech

• emotional regulation

• impaired judgement

• cognitive issues

• inability to cope

• increased risks

• challenging behaviours and impulsivity

• loss of motivation

• loss of pleasure

• impacts on communication

• diminishing functioning

• impacts on relationships, work, education>>>

• impacts on income, housing etc.

nursing interventions: psychological

engagement is a critical step – address issues of concern to the person

• first contact is highly influential – more successful if first contact is before major crisis

• vital to identify and empathise with the focus of distress and suffering

• put the person at ease

• calm emotional atmosphere, support

• acknowledge, respect, listen, and find common ground

• develop rapport

• challenge poor self-esteem • self esteem journal • give positive feedback • important roles, loved ones • collage of interests/achievements

• work with stress reduction and management and coping skills

nursing Interventions: ADLs

nurses help with self care-ADL, nutrition, sleep-help with time management, sequencing of tasks, gentle reminders, organisation

Personal hygiene • Assess ability to meet personal hygiene needs • Assist to meet daily needs, where necessary

Nutritional intake • Assess hydration and nutritional status • Assist to meet hydration and nutritional status

nursing interventions communication

effective communication • respect privacy • brief conversations • keep it simple • don’t dismiss what they say even if unusual • avoid arguing or debating with them

Active listening • reflect the client’s feelings • reframe their story • check for understanding • what are the major themes in speech/thought? • do these suggest unmet needs? • could these needs be met?

nursing interventions: client and family education

• the disorder

• early warning signs and triggers

• relapse, action plan if signs of relapse evident, timeframe for action etc.

• medications-effects/side effects, dose

• role of family therapy

• agreed rules and obligations for family

nursing Interventions

hallucinations • assess type, extent and content, do the

hallucinations express unmet needs? Could these be met?

• assess command hallucinations and coping/distraction strategies (harm prevention) –how compelling are they?

• close observations if compelling/perhaps PRN medication

• identify triggers of hallucinations-stress, noise, machines, certain people/situations - identify how to cope with these

• reality basing-reassure that the hallucinations are part of the illness and that although you can’t hear/see/feel/taste/smell them you know that they can

nursing interventions

delusional thinking:

• assess the risk the delusions might pose for others and prevent (close constant observation/PRN medication)

• assess the content-what are the underlying feelings/needs?

• reality basing: don’t agree with the delusions but convey that you understand how real the belief is to the client

• identify triggers: does the delusion manifest in times of stress

• provide a quiet and peaceful environment

nursing interventions

Violence prevention

• encourage to talk (ventilate) rather than act out feelings • give personal space • set verbal limits • avoid touching client • avoid crowding them • consider what set the person off –triggers • can the issue be addressed and plans made for an alternative to aggression next time?

Violence management

• time out, quiet room

• can require more extreme measures i.e. seclusion, restraint, medication

• be self-aware-were you respectful or did your behaviour agitate the client?

nursing interventions

fear, anxiety, paranoia

• assess for level of fear, anxiety, paranoia

• reassure that they are in a safe environment

• be self-aware-how could your behaviour be misinterpreted

• manage and limit anxiety –relaxation techniques, change environmental stimuli, exercise

• simple coping strategies

• relaxation • visualisation • guided imagery • self care • if needed, PRN medication

nursing interventions

disordered thinking • assess the content and extent of disordered thinking

• assess the degree to which thought disorder affects activities of daily living

• speak clearly and use unambiguous language

• assess the effectiveness of medication

• use diversional activities (go for a walk, play a game)

• assess the impact of other environmental stimuli

but remember the person may be paranoid and refuse to talk

they may feel persecuted or that they are being poisoned etc.

social interventions: holistic approach

• with client’s permission, involve family, carers and significant others and provide support and education to all

• address practical problems: • finance • housing • transport • child care/custody • marriage/other relationship

issues • education • legal • employment commitments

Social skills training

• role play, practice specific skills • modelling • social activities/behaviour (games,

other activities)

other therapeutic interventions

• crisis intervention

• psychotherapy: individual; motivational interviewing; CBT (emphasises the meaning and impacts of the experiences)

• behaviour therapy: classical and operant conditioning

• group therapy: problem focused; interpersonal

• family therapy: effect change within the family system

• psychosocial rehabilitation: recovery process

• case management: service delivery within community

client needs to be over the acute phase of psychosis for these

antipsychotic medications

Older types –called typical antipsychotics or phenothiazines

• Haoloperidol (Serenace/Haldol) • Chlorpromazine (Largactil) • Thioridazine (Melleril) • Trifluperizine (Stelazine) • Fluphenazine Deconate(Modecate Injection)

1990s newer types- called atypical anti-psychotics • Clozapine (Clozaril) • Respiridone (Risperdal) • Olanzapine (Zyprexa)

• reduce positive symptoms and moderate negative symptoms

• prevent the relapse of the illness

• a single episode psychosis -medication may be required for 1 – 2 years

• 2 or more episodes-recommendation is 5 years

Psychopharmacology-goals of antipsychotic medications

Why are so many people reluctant to take anti-psychotic medication?

• Typical anti-psychotics have dangerous and unpleasant side-effects

• Peripheral nervous system • dry mouth • headache • constipation • urinary hesitancy • photophobia • decreased lacrimation • sexual dysfunction

• Central nervous system • sedation • Pakinsonian effects [blank, mask-like expression, drooling, tremor muscle rigidity and

shuffling gait] • akathesia [restless leg syndrome] • increased likelihood of seizures

a major part of nursing care is monitoring for these side-effects and doing on-going MSE to see if they are having the desired effects

anti-psychotics continued…

Other severe adverse effects

• Neuroleptic malignant syndrome –life threatening-cardiac, BP, sweating, muscle rigidity, stupor (of those who get it 30% morbidity)

• Tardive dyskinesia –irreversible side-effect of long term anti-psychotic medication-tremor, muscle spasms, tongue rolling and lip smacking

• Agranulocytosis-dangerous lowering of production of white blood cells

The new atypical anti-psychotics also have some severe side-effects that require close monitoring (See Ucok and Gaebel 2008 at http://www.ncbi.nlm.nih.gov/pmc/articles/PMC2327229/

nursing interventions: psycho-education on medication

• weigh up benefits and problems

• reassurance

• need to take medications as prescribed

• likelihood that medication may be required for some time

• explain side effects and issues of sedation and fatigue, e.g. operating machinery

• avoid alcohol and not to mix with illicit drugs

• not double up on missed doses

• not to stop taking, even if they feel well

• provide repeated psycho-education regarding efficacy

Living with schizophrenia - Ashley

activity

You are managing a person who believes that the water is poisoned and, subsequently, refuses to drink

What strategies may assist the patient to maintain hydration?

deeper understanding?

Books: Strange Places – Will Elliot Tell me I’m here - Anne Deveson

Films:

A Beautiful Mind

An Angel At My Table