Psychiatric Nursing for the newbies!!!

Being a new nurse on a mental health unit is not always easy, but it is always worth it.   You deal with the population who have known trauma, dealt with stigma on a daily basis and have had people, even their own loved ones mis-understand or fail to understand them. 

Many patients are not ready to trust you or to open up. They come to you in crisis and in their most vulnerable time of need, but if they cannot trust you or establish a therapeutic relationship with you, they will not open up to you. That’s where your real nursing skills; mainly; the therapeutic communication, empathy, compassion, and client engagement come to play.

 Mental health nurses often see and hear things that test their own beliefs and ethics.   They hear language often beyond their personal comfort level.  But it’s difficult to help patients without truly making a judgement.   Nurses and clinicians can get biased too.  They read case histories and hear the things the client has done, especially those on forensic units.  Yet, a great psych nurse knows how to keep her own personal bias on check and be there for the client.  No matter what he or she has done; she is here in the unit for the client and his/her needs always take priority.

How to survive on a psychiatric unit?

1.  Get to know your patients and build a trusting relationship

As with any relationship, building a therapeutic relationship with a client requires time, patience, trust and perseverance. 

Listen:

Give them the opportunity to express themselves

Listen also to the environment.  Listen to the sounds in the milieu.  Get a feel for your milieu.  When you practice walking around the milieu in the beginning of your shift; you get a feel for how your day is going to turn out.  Get the cues from the environment.

Look for patients you are going to have an interaction with today.  Those could be your assigned patients or the patients who need help the most.  Give them a place to talk that is free from distractions, is private and quiet.

Look for non-verbal cues:  Is he maintaining eye contact; is his gaze downwards, is he/she fiddling with clothes, fingers, nails or with anything else?  Are his/her fists clenched/relaxed?  Is he/she calm, relaxed, restless, perspiring, hyperventilating?  How’s the tone and voice inflection- low, moderate, screaming?  

Provide verbal prompts: ‘Really’, ‘What happened next?”  ‘Please go on’, ‘I hear you’……

What information did the Nurse get from this conversation?

-The life situation of the patient, the probable homelessness…

-Patterns of behavior; the patients coping strategies, how the patient responds to certain situations, substance use issues, vulnerability…

-Mood and affect of the patient, judgement and insight, decision making processes, rationalization of harmful situations

Nonverbal cues:

General appearance, self-care, display of emotions, lability in affect, anxiety and restlessness, uncertainty

•  Daily assessments:

The regular questions that I routinely ask include:

How do you feel today?

On a rate of 1-10, how do you rate your anxiety/depression/restlessness/stress/pain today?

Have you been hearing voices/seeing things?  What are the voices saying?  What brings on these voices?  What helps when you feel overwhelmed by them?

Did you have visitors yesterday?  Who do you approach for, for support?

Where would you go after discharge?  What are your plans?  School?  Work?

Can we review the coping skills we reviewed the other day?  Which one do you plan to use today?

Is there any way I can help you with today?

These questions help the clients realize that the nurse cares and is genuine with the concern.  However, do not just confirm to these questions. 

Insider Tips:

Most of the time, we nurses are often seen as just being the people that hold the keys and give out medication. That’s were relationships develop.  That’s when the barriers are broken and trust is built.  The clients at this point begin to see their nurses as someone they can relate to; someone who will advocate for them, someone in whom they can confide to and seek help. 

Guidelines for Communicating With a Person with Mental Illness

•Be respectful to the person and be attentive to his needs. When someone feels respected and heard, they will more likely listen to what you have to say.

•If you know your patient is hallucinating, maintain physical boundaries.  Give them space and avoid initiating physical contact.  Know that, no matter what you say, their hallucinations and delusions are their reality and no amount of coaxing will change that.  Let them know that you understand that their thoughts are real to them.  If they are afraid, reassure them. 

• Always keep your promises.  If there is a valid reason for not being able to keep them, let them know.  Do not just pass them on to another person just to get rid of them. This may save you the trouble and inconvenience in the short run but may come back to haunt you later when he/she starts escalating. If you have to refer them to another person, let them know.

•If and when needed, set limits with the person and always maintain boundaries. Let them know they are important but you have only a certain amount of time you can spend with them.  Set clear limits about your availability, frequency of encounters, and appropriate patient behavior while in the milieu.  Be consistent.

What not to do or say to your patients:

1.  Calm down.  Don’t worry

Don’t ask a patient to just ‘calm down’.  Instead tell him, ‘Can we sit over there and discuss this?’  “I know this must be hard on you, can we sit down and calmly talk about this?”

Or phrases like, “I know this is important for you, but I can’t help you when you scream”. 

• “NO”

An abrupt ‘no’ gets the patient on the defensive.  Do not attempt to convince the patient to do the right thing. Instead of saying “You should” or “You shouldn’t”, say “You are expected to”. Establish the rules and reinforce them.  Again consistency is the key.  This establishes normative behavior and depersonalizes required actions.  If they cannot have telephone privileges for any reason, be matter of fact.   If they ask for a snack during the ‘non snack’ hours, redirect them to the meal and snacks timings.

• Nagging

“You told me you would shower today.  I thought you meant it.  Why won’t you shower?  You really need one”

Remember, what tends to irritate a normal person will impact a sensitive, paranoid or psychotic patient even more.

• Power struggles

Never engage in power struggles. Nurses experience annoyance and anger when their caring attitude and competence are questioned.  Know your limits.  Know when to withdraw.  Choose your battles when you deal with patients exhibiting excessively manipulative behaviors.

• Touch

Avoid touching the patients without warning:  It may set off the patients experiencing delusions or paranoia. Although in mental health, you need to set firm boundaries anyways, touch should occur only during assessments

• Never violate boundaries:

This cannot be re-enforced enough.   Any ‘extra’ activity or favor you do can come back to bite you.  Be consistent while enforcing rules.  If you think your boundaries with a particular client might have been compromised, report it immediately to your supervisor and take actions to halt the progression, even if it means the end to your nurse-client relationship.  That extra snack or a bottle of juice can be the first step towards your downfall.  Be firm, be genuine, be trust worthy.

• Hallucinations and delusions

Do not re-enforce the client’s hallucination.  Do not go on and on about it.  On the same note, do not deny or argue about his delusional belief.  Know that his belief is real to him.  The voices he hears are real to him.

Nursing Documentation

What should your daily note contain?

Your assessment findings:

Subjective comments:   Documented it as said by the patient.

E.g.:  Instead of documenting patient had disorganized speech, document it as; the patient said, “I am the King and I rule the world”.

Objective behaviors:

 Peer and staff interactions and interactions with visitors if any.

 Participation or refusal to participate in group activities.

 Medications:  Compliance or refusals, reports of side-effects, patient’s view of the medications

Symptom Status:

Absence or presence of symptoms, progress or regression of symptoms, improvements if any.

Special occurrences:  Any occurrence of violent episodes, falls or withdrawals, use of seclusion or restraints, possession of contrabands or newly emergent medical needs

Nursing interventions:  The golden rule applies.  “If you didn’t document it; it didn’t happen”.  Vital signs or reports of any other assessments performed; any health educations, therapeutic interventions, medication administrations or any interventions provided need documentation.

Mental Status Examinations:

The Mental Status Exam (MSE) is the psychological equivalent of a physical exam that describes the mental state and behaviors of the person being seen. It includes both objective observations of the clinician and subjective descriptions given by the patient.

Appearance

The appearance of the patient may provide some clues as to their lifestyle and ability to self-care abilities:

Demographics:  Patients gender, age, race, marital status

•Distinctive features:  May include body frame, any apparent weight loss/gain, skin texture and health, any tattoos, open wounds, apparent bandages, dressings, fractures, gait, mobility

•Clothing: appropriate to the weather, too many clothes, make-up- too much/appropriate

•Grooming/hygiene:  clean body/hair/nails, signs of self-neglect, body odor

•Evidence of self-harm:  cuts/scratches, abrasions, on skin

Example of Appearance:  This 40 year old year single, Caucasian male was casually dressed in a clean T-shirt, jacket and shoes.

Behavior

A patient’s non-verbal communication may provide insights into their current mental state:

•Eye contact:  Appropriate, avoidant, intense

•Psychomotor activity:  Agitation, aggression, hyperactivity, pacing, restlessness, fidgety, clenched fists, sweating, intruding into interviewer’s personal space, and retarded activity

•Body language / gestures / mannerisms

•Movements:  Coordinated involuntary movements, muscle spasms and contortions, repeated movements, rigidity

•Rapport and attitude:  Co-operative, relaxed, suspicious, guarded, over-familiar, hostile, ability to provide reliable information

Example:  She was irritable, held an intense stare and kept clenching her fists throughout the interview, however relaxed after a while and hesitantly responded to the questions asked. She was judged to be a poor historian.

Speech

The quality and quantity of the client’s speech is of importance here.  While quality includes coherence, clarity, appropriateness and voice volume and tone; quantity often refers to the rate of speech. 

Quality:

Pressured speech:  Excessive/lengthy speech with irrelevant details typically seen in mania

Circumstantiality/Tangentiality:  A perfect example of circumstantial speech would be when a client is asked about what he had for lunch, he responds by saying how weeds killed the crops worldwide and why smoking should be banned and so on before finally saying he had spaghetti for lunch.   

Perseveration:  Repetition of the same words or phrases

Flight of Ideas/Loosening of associations:  Rapid topic changes, with no connection between ideas

Quantity:

•Mute, refuses to talk/minimal speech/excessive speech/hyper verbal

• Thought Block:  A sudden interruption in his speech, not able to remember what he was going to say; loss of concentration may be due to hallucinations

Spontaneity:  Prompt response/delayed response

Volume:  loud as in mania; quiet as in depressed or in intoxication

Tone and fluency:  monotone/clear articulation/slurred speech

Example:

Speech was normal in terms of tone and volume; slightly pressured, volume was normal; rate of speech was pressured with a tendency to focus on the negative circumstances surrounding his recent divorce.

Mood and Affect

Mood and affect both relate to emotion, however, they are not the same thing:

•Affect represents an observed emotion.  Commonly used examples would be euphoria, anger, and blunt/flat, restricted, apathetic, broad/expansive/animated, Labile (easily changed between states) or sad.

•Mood refers to client’s endorsement of what he feels

Examples would be:  Low/depressed, Anxious, Angry/irritable, Sad, hostile, indifferent, euthymic, dysphoric, detached, elated, euphoric, anxious, animated.

Appropriateness to situation, consistency with mood, congruency with thought content.

Example:

Mood: “sad”

Affect: constricted and dysphoric. Mood congruent with content.

Thought and Perception:

Thought Processes:

Logic, relevance to situation, general thought flow/latency.

Example:  Thought process is linear/logical and goal directed vs paranoid, evasive, racing thoughts, presence of neologisms, grandiosity etc.

Thought Content: 

Possible questions for patient should include:

What have you been thinking lately?

Is there something that scares you, worries you, or makes you anxious?

Do you feel like people are trying to steal your thoughts or any inserting thoughts in your head?

Do you ever see (visual) or hear (auditory), things that others do not see or hear?  Perhaps some smell (olfactory), taste (gustatory), and feel (tactile) things that those around you don’t seem to be feeling?

Do you at times mis interpret things in your surroundings causing you fear or anxiety, like; muffled sounds, certain shadows, interpreting rope for a snake? (identifies perception issues)?

Do you feel like life is not worth living, that there is no hope, or nobody understands you?

Have you ever thought of ending your life?

Do you feel like hurting others who you think have wronged you?  Or may be trying to hurt you?

Thought form:

  Racing thoughts/ retarded

•Incoherent – makes no logical sense

•Circumstantial – lots of irrelevant/unnecessary details (not to the point)

•Tangential:  Patient jumps from one topic to another without actually returning back to the said topic

•Flight of ideas:  too many ideas, racing thoughts

•Perseveration – repetition of a particular word or sentence

Insight and Judgment:

Insight and judgement can be identified by asking certain specific questions to the client.

Possible questions for patient may include:

What brings you here today?  What do you think was the problem? Do you believe that you need professional help?  Do you understand the charges that are against you?

What would you do if you saw a fire in your kitchen?

What would you do if the person walking ahead of you dropped something from his pocket?

If you found a stamped, addressed envelope on the street, what would you do with it?

Attention and Concentration

 Assess for attention span or easy distractibility:

Test 1:    Do you know how to spell ‘World”?

Now can you spell it backwards?

Test 2:  Starting with 100, subtract 7 from 100, and then keep subtracting 7 from that number as

far as you can go.

Test 3:  I will name three objects to you, repeat them after me and after 5 minutes, I will ask you to repeat them to me again.

Orientation:

QUESTIONS TO ASK

Could you give me your complete name please?

 Can you tell me today’s date?

Do you know the day of the week? What month? What year?

How would you describe the situation we are in?

Do you know where you are?  The location?  What kind of place?

Do you know who I am?

MEMORY

Assess long, term, short term and intermediate memory:

QUESTIONS TO ASK:

Long-term memory:

•What was the name of your first pet?

•What was the name of the school you went to?

Short-term memory:

•What did you eat this morning?

•What was the topic of today’s group discussion?

Intelligence:

QUESTIONS TO ASK

 •Who is the president of the United States?

•What is the capital of US?

SAMPLE MENTAL STATUS EXAMINATION

 The client is a 43-year-old, Caucasian, married man who is well built, reasonably well dressed and groomed.  He is cooperative with the interviewer and is judged to be an adequate historian.  His gait is steady. Eye contact is intense at times but overall fairly appropriate. His speech is anxious in tone, conversational in prosody and volume. Normo-kinetic, is appear physically restless at times. Mood is reported as good, with blunted affect. Thought process is mostly linear though occasionally belies a mild disorganization evident in connected different ideas together. No suicidal or homicidal ideations noted. Denies perceptual disturbance and does not appear to be responding to internal stimuli.  Recent and remote memory are good.  Judgment is fair though still not ideal, insight is fair.

Concluding words………

Mental illness is without any doubt one of the most challenging illnesses to treat.  There are no definite baselines or lab values to help you determine the extent of the illness.   Although people have come up in the open, in the recent past, stigma still persists.    The path to recovery from a mental illness is not easily defined and definitely not lined with roses.  The profession in itself is a challenge; while on some days it might seem like a walk in the park, on other days; it is just a Jurassic park.

Know that not all patients will get better, nevertheless it will be one of the most rewarding decisions you’ll ever make

Keep looking ahead for more articles on mental health nursing!!!

Meanwhile, do not forget to look at my previous article for nurses who wish to venture into this beautiful discipline!

Why mental health nursing?

Is there anything else you would like to know about the profession? Leave your messages, suggestions, any constructive criticism in the comments section to help me serve you better!