NCLEX-RN PREPARATION PROGRAM

1. NCLEX-RN PREPARATION PROGRAM MENTAL HEALTH DISORDERS Module 6, Part 1 of 3

2. Module Description • This module will prepare the graduate nurse to pass the NCLEX exam in the area of mental health. Included in this module is a review of the following areas: • Therapeutic communication and milieu therapy • Nursing process • Mental illnesses and disorders • Psychopharmacology • Life span development issues

3. Introduction The nurse must be aware of the therapeutic or nontherapeutic value of the communication techniques used with the client—they are the “tools” of psychosocial intervention.

4. What is Communication? • Interpersonal communication is a transaction between the sender and the receiver. Both persons participate simultaneously. • In the transactional model, both participants perceive each other, listen to each other and simultaneously engage in the process of creating meaning in a relationship.

5. Communication • Includes: dominant language, dialects, contextual use of language; • Paralanguage variations such as voice volume, tone, inflections and willingness to share thoughts and feelings; • Nonverbal communications such as eye contact, gesturing and facial expressions, use of touch, body language, spatial distancing practices and acceptable greetings;.

6. Communication • Communication is: Temporary in terms of past, present and future orientation of worldview; Clock versus social time, and the amount of formality in use of names

7. Communication Therapeutic communication techniques encourage the client or other individual with whom the nurse is communicating to express their thoughts and feelings.

8. Technique Active Listening Broad Openings Description Carefully noting what the client is saying and observing the client’s nonverbal behavior Encouraging the client to select topics for discussion Communication

9. Technique: Clarifying Focusing Description: Making the message clearer, to correct any misunderstanding, and to promote mutual understanding Directing the conversation onto the topic being discussed Communication

10. Technique: Informing Open-ended questions Description: Giving information to the client Encourage conversation because questions require more than just one-word answers Communication

11. Technique: Paraphrasing Reflecting Silence Description: Restating in different words what the client said Directing the client’s question or statement or feelings back to the client Allowing time for formulating thoughts Communication

12. Approval/Disapproval Asking excessive questions Changing the subject Close-ended questions Giving advice False reassurance Value judgments Why questions Minimizing the client’s feelings Communication Non-therapeutic Communication Techniques

13. NCLEXCommunication Question Guidelines • Look for the option that indicates the use of a therapeutic communication technique. • Eliminate non-therapeutic communication techniques. • Look for the option that focuses on feelings, concerns, anxieties or fears. • Consider cultural differences as you answer the questions.

14. Impact of Preexisting Conditions • Both sender and receiver bring certain preexisting conditions to the exchange that influence both the intended message and the way in which it is interpreted. • Values, attitudes, and beliefs. Attitudes of prejudice are expressed through negative stereotyping. • Culture or religion. Cultural mores, norms, ideas and customs provide the basis for ways of thinking. How do these affect the relationship?

15. Impact of Preexisting Conditions • Social status. High-status persons often convey their high-power position with gestures of hands on hips, power dressing, greater height, and more distance when communicating with individuals considered to be of lower social status. • Gender. Masculine and feminine gestures influence messages conveyed in communication with others.

16. Impact of Preexisting Conditions • Age or developmental level. The influence of developmental level on communication is especially evident during adolescence, with words such as “cool,” “awesome” and others.

17. Impact of Preexisting Conditions The environment in which the transaction takes place. Territoriality, density, and distance are aspects of environment that communicate messages. • Territoriality–the innate tendency to own space • Density–the number of people within a given environmental space • Distance–the means by which various cultures use space to communicate

18. CommunicationCultural Considerations With regard to communication, there are three cultural characteristics to consider: Communication style Use of eye contact The meaning of touch The goal is to promote cultural sensitivity and culturally competent care that respects each person’s right to be understood and treated as a unique individual.

19. Communication Cultural Consideration Communication Style African Americans • Personal questions asked on initial contact may be viewed as intrusive

20. Communication Cultural Consideration Communication Style Asian cultures • Open expression of emotions not valued • Silence is valued • Criticism or disagreement not expressed • Head nodding does not necessarily mean agreement • May interpret the word “no” as disrespect for others • Do not use hand gestures

21. Communication Cultural Consideration Communication Style Americans of Northern European descent • Silence can be used to show respect or disrespect, depending on situation • May show little facial emotion because they value concept of self-control

22. Communication Cultural Consideration Communication Style French and Italian Americans • May use expressive hand gestures and animated facial expressions

23. Communication Cultural Consideration Communication Style Hispanic Americans • May use dramatic body language such as gestures or facial expressions to express emotion or pain • Confidentiality important • Direct confrontation disrespectful, and expression of negative feelings impolite

24. Communication Cultural Consideration Communication Style Native Americans • Silence indicates respect for the speaker • Speak in a low tone of voice and expects others to be attentive • Body language is important • Obtaining input from extended family important

25. Communication Cultural Consideration Use Of Eye Contact Asian Cultures • Eye contact is limited and may be considered inappropriate or disrespectful

26. Communication Cultural Consideration Use Of Eye Contact European (White) Americans • Eye contact viewed as indicating trustworthiness Native Americans • Eye contact may be viewed as a sign of disrespect • Client may be attentive even when eye contact is absent

27. Communication Cultural Consideration Use Of Eye Contact Hispanic Americans • Avoiding eye contact with a person in authority indicates respect and attentiveness

28. Communication Cultural Consideration Meaning of Touch African Americans • Comfortable with close personal space when interacting with family and friends European (White) Americans • Tend to avoid close physical contact • Respect personal space

29. Communication Cultural Consideration Meaning of Touch Asian Cultures • Prefer formal personal space except with family & close friends • Usually do not touch others during conversation • Touching unacceptable with members of the opposite sex; if possible, a female client prefers a female health care provider • The head is considered to be sacred; touching someone on the head may be considered disrespectful • Avoid physical closeness and excessive touching and only touch a client’s head when necessary, informing before doing so

30. Communication Cultural Consideration Meaning of Touch Hispanic Americans • Comfortable with close proximity with family, friends and acquaintances • Protect privacy • Tactile and sensory are important - use embraces and handshakes • Ask if it would be all right to touch a child before examining him or her

31. Practice Question - Communication While communicating with a client, a nurse decides to provide the client with feedback. The primary reason for this is that giving appropriate feedback makes it possible for the nurse to: A. Present advice B. Explore feelings C. Provide information D. Explain behavior

32. Overview of Psychiatric Mental Health Nursing Mental Health • The ability to see oneself as others do • Fit into one’s culture and society • Indicators of mental health • Positive attitudes toward self, growth, development, self actualization, integration, autonomy, reality perception and environmental mastery.

33. Overview of Psychiatric Mental Health Nursing Mental Illness • Inability to see as others do • Not having the ability to conform to the norms of the culture and society

34. Overview of Psychiatric Mental Health Nursing Medical Diagnosis of Mental Illness Classified according to the Diagnostic and Statistical Manual of Mental Disorders, fourth edition (DSM-IV), of the American Psychiatric Association.

35. Overview of Psychiatric Mental Health Nursing The DSM-IV Classification system uses five axes for diagnostic purposes: Axis I: Adult and child clinical disorders Axis II: Personality disorders; mental retardation Axis III: General medical conditions Axis IV: Psychosocial and environmental problems Axis V: Global assessment of functioning (0-100)

36. Mental Health Nurses • Need both general and specific cultural knowledge • If above absent, nurses won’t know what questions to ask • Generalizations made are almost certain to be oversimplifications

37. Mental Health Nurses • Must first address their own personal and professional knowledge, values, beliefs, ethics and life experiences in a manner that optimizes assessment of and interactions with culturally diverse clients

38. Mental Health Nurses • Self awareness includes a deliberate process of getting to know oneself; one’s own personality, values, beliefs, professional knowledge, standards, ethics and the impact of the various roles one plays when interacting with individuals who are different from oneself.

39. Overview of PMHN Duties/Responsibilities Psychiatric Mental Health Nurses (PMHNs): • Assess, formulate nursing interventions, and implement individualized treatment plans with culturally competent interventions. • Document progress. • Document changes. • Attend interdisciplinary meetings to discuss progress, issues and treatment updates. • Complete assault prevention training and other required trainings.

40. Overview of PMHN Duties/Responsibilities • Uphold professional standards of behavior, appearance, language, dress and demeanor. • As a member of an integrated treatment team, assist families, agency representatives and other staff. • Understand the legal framework for the delivery of mental health services.

41. Assessment Nsg Dx Outcome ID Planning Implementation Evaluation Gathering and organizing data Identify (ID) areas for intervention Setting outcome criteria Planning action to meet the goals Carrying out actions Evaluating if goals (outcomes) are met Nursing Process

42. Mental Health Assessment INTERVIEW During the interview, the nurse uses verbal and nonverbal therapeutic communication techniques to collect subjective and objective data about the client.

43. Mental Health Assessment Purpose • Establish rapport • Determine reason client is seeking help • Obtain an understanding of current illness (via client, family, chart review and interdisciplinary team) • Understand how this illness has affected client’s life • Identify client’s recent life changes or stressors

44. Mental Health Assessment Gather current life style information • Social patterns • Interests and abilities • Relationship issues • Substance use and abuse

45. Mental Health Assessment Assess for risk factors • Suicide or self-harm • Assault or violence • Physiological instability

46. Mental Health Assessment • Appraisal of health and illness • Info on previous psychiatric problems or or disorders • Current and past medications • Physiological coping responses • Psychological coping responses • Resources

47. Nursing Conditions During Assessment • Self-awareness • Accurate observations • Therapeutic communication • Establish nursing contract • Obtain information • Organize data

48. Analyze Data/Norms Formulate Nursing Diagnoses • Identify patterns in data • Compare with norms • Analyze and synthesize data • Identify problems and strengths • Validate problems with client • Formulate nursing diagnoses • Set priorities of problems

49. Outcome Identification (Goals) • Identify expected outcomes individualized to client • Planning • Interventions to attain outcomes • Nursing Conditions • Application of theory • Nursing Behaviors • Prioritize goals • Identify nursing activities • Validate plan with client/family • Key Elements • Individualized, collaborative, documented

50. Implementation • Implements interventions identified in the plan of care • Experience • Evidence-based practice • Nursing behaviors • Know available resources, implement, generate alternatives, coordinate with other team members