Monthly Archives: December 2011

Psychiatric/Mental Health: The Basics

The focus of this psychiatric/mental health nursing is usually around 4 main concepts:

  • therapeutic communication
  • safety
  • medications
  • specific psychiatric disorders

Therapeutic communication:
Communication is vital to the general nursing field, not just in psych, but it is especially important when interacting with a patient in the psychiatric setting. Much of the techniques learned in assessment applies such as reflection, active listening, empathy, etc. However, it is important to first look at the overall patient situation and determine which statement is most appropriate. For example, for a patient who is suicidal, you would want to ask more direct questions even if they seem very blunt such as “have you thought about harming yourself?”

Recall that in the model Maslow’s Hierarchy of Needs, the care of the patient follows a stairstep priority list starting with physiological needs, followed by safety, emotional needs, self esteem. In psych, safety is always the priority. Consider interacting with an escalating angry patient. First step would  be to escort other patients away from the angry patient. Think about a patient who just told you he wants to kill himself. First thing would be to remove all objects that he could use to harm himself, such as ropes, bedsheets, even coke cans. Safety of the patient, other patients and nurse is crucial in these settings.

Medications aren’t administered by students during the clinical shift, however, it is important for us as nurses to know the ins and outs of psych medications. There are several classes of medications covered in this course:

  • Antidepressants – Selective Serotonin Reuptake Inhibitors (SSRIs), Tricyclics (TCAs), Monoamine Oxidase Inhibitors (MAOIs) and Atypicals
  • Antipsychotics – Conventionals and Atypicals
  • EPS drugs
  • Benzodiazepeines and related anxiolytics
  • Mood Stabilizers – Lithium, antiseizure medications
  • ADHD meds
  • Alzheimer’s agents
  • Herbals
  • Hypnotics
It isn’t enough to simply know what kind of drug it is, but also what is the specific name. Prozac is a SSRI, Geodon is an atypical antipsychotic.  There are several techniques to memorize the different drug names. I’ve seen pictures, acronyms and color coding. Once you know the different names and correlating class of drug, know their mechanism of action. Majority of these drugs work on neurotransmitters in the brain which in turn may produce the therapeutic effect as needed to relieve symptoms. Knowing the side effects is especially important. Some of these medications produce very uncomfortable side effects which may contribute to noncompliance. Teaching patients how to manage the side effects and administering the appropriate treatment is a critical part of medication administration.

Psychiatric Disorders:
There are several different psychiatric disorders covered in this coursed, including:

  • Schizophrenia
  • Anxiety disorders
  • Addictions
  • Depression
  • Bipolar disorder
  • Somatoform, Factitious, Dissociative disorders
  • Cognitive disorders
  • Personality disorders
  • Child/Adolescent disorders
  • Eating disorders

Alongside, there are other topics including death and dying, abuse, crisis intervention, etc. For each of the psych disorders, concentrate on the manifestations of the disorder, medications and relevant treatments, role of the nurse in caring for this particular patient, appropriate diagnoses and outcomes and patient teaching in managing their illness.

Whether you’re interested in working in the field of psychiatric nursing or not, the skills learned in this course may apply to all fields of nursing. Whether you’re working in critical care or general med/surg, there is a high possibility that some patients you meet may have comorbid psychiatric problems. Viewing the patient holistically includes addressing mental health and a efficient nurse is one who is competent in not only the medical, but the emotional and mental aspects of nursing care.

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Medical-Surgical Nursing: The Basics

Med/Surg is like the meat and potatoes of nursing, with Foundations being the dinner plate and Assessment being the mashed potatoes. It’s important to get a grasp of the general med/surg content, concentrating on:

  • pathophysiology of certain conditions and clinical manifestations
  • nursing interventions R/T the pathophys
  • related medications and treatment options
  • patient teaching

The Lewis textbook does a great job of organizing the content in a comprehensive and flowing manner. The chapters begin with basic pathophys related to a certain disease process followed by clinical manifestations. By now, much of the terminology used should be familiar post-Foundations. It’s important to differentiate specific clinical manifestations with a specific disease, because there are quite a few that overlap with other conditions. For example, nausea and vomiting may be a common symptom amongst several GI conditions, but a symptom like pain relieved by food is more specific to duodenal ulcers (as opposed to gastric ulcers).

Once you’re familiar with the clinical manifestations of the disease, relevant diagnoses and outcomes are important to address those symptoms. It’s also important to recognize what symptom that diagnosis addresses and if they match. For example, the diagnosis Ineffective airway clearance is more relevant to excess mucus in the airway as opposed to Ineffective breathing pattern which is more relevant to labored breathing. Remember, as nurses we don’t necessarily treat the disease, rather we treat the symptoms.

Following that, knowing the role of the nurse and responsibilities in the collaborative care is critical. A simple way to study for this is by linking the pathophy with the clinical manifestations and then link that to a specific nursing intervention. For example, a patient with COPD often displays dyspnea (difficulty breathing). The pathophysiology behind that is chronic inflammation of the airway and excess mucus. As a nurse, what are some interventions you can do? Let’s start with the obvious – oxygen. Assuming there is a standing order, the nurse would apply oxygen to the patient (FYI: patients with COPD should never be given oxygen more than 2-3 liters/minute as it may cause them to stop breathing!). Alright, so give the patient oxygen, what else is relevant? How about raising the head of the bed to allow for the lungs to expand? Often times a test question will ask for a priority intervention. In this case, what is the one action that the nurse can do immediately? It usually would be raising the head of the bed. Once envision in your mind yourself as the nurse caring for this patient, it may help facilitate the way you study for this course.

In addition, patient teaching is important. What does the patient need to know about self care before he or she is discharged? Using the above COPD example, I could teach the patient to take his/her medications regularly, turn/cough/deep breathe to facilitate lung clearance and pursed-lip breathing to prevent air trapping.

The exams for Med/Surg focus mainly on nursing care with some assessment and patient teaching. When reading the question, picture that patient in your mind. It’s important to differentiate real world from NCLEX world. Often times, these questions are in a setting where you have as much time as you have and can only do one thing in the room before leaving. Remember to identify positive from negative questions, as well as priority questions. What can the nurse do immediately? Before I call the doctor, what information have I gathered? If the question does not have any assessment findings/information in the root of the question, usually you would need to assess first.

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