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Senior Content Strategist: Yvonne Alexopoulos
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Senior Content Development Specialist: Danielle M. Frazier
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Printed in the United States of America
Dedication
This book is dedicated to people who are living with and recovering from mental illness and to the nursing students and registered nurses who focus on supporting this recovery.
Reviewers
Leslie A. Folds Ed D.; PMHCNS-BC; CNE
Associate Professor of Nursing School of Nursing
Belmont University
Nashville, TN
Phyllis M. Jacobs RN, MSN
Assistant Professor Emeritus School of Nursing
Wichita State University
Wichita, Kansas
Susan Justice MSN, RN, CNS
Clinical Assistant Professor
College of Nursing
University of Texas at Arlington College of Nursing and Health
Innovation Arlington, Texas
Chris Paxos PharmD, BCPP, BCPS, BCGP
Pharmacotherapy Specialist
Department of Pharmacy
Cleveland Clinic Akron General Akron, Ohio
Associate Professor of Pharmacy Practice
Department of Pharmacy Practice
Northeast Ohio Medical University, College of Pharmacy
Rootstown, Ohio
Associate Professor of Psychiatry
Department of Psychiatry
Northeast Ohio Medical University, College of Medicine
Rootstown, Ohio
Preface
As with previous editions, the sixth edition of the Varcarolis' Manual of Psychiatric Nursing Care Planning supports students and practitioners in planning realistic, evidence-based, and individualized nursing care for their patients. This thoroughly updated edition of the Manual provides readers with a foundation for clinical work in contemporary psychiatric settings. The chapters are logically and intuitively arranged in five parts:
• Part I provides a snapshot of basic psychiatric concepts and tools. These chapters focus on the nursing process, therapeutic relationships, and therapeutic communication.
• Part II explores specific diagnostic groups, an overview of major disorders within these groups, and guidelines for developing and providing psychiatric nursing care.
• Part III discusses psychiatric crises such as suicide and family violence and outlines the nursing process as it pertains to these crises.
• Part IV is devoted to psychopharmacology. Eight chapters provide essential information regarding specific classifications of drugs such
as antipsychotics and antidepressants.
• Part V provides a summary of nonpharmacological approaches. Whereas psychotherapeutic models are mentioned in the clinical chapters, Chapter 29 provides an overview of evidence-based therapies such as cognitive–behavioral therapy. Chapter 30 introduces the increasingly common brain stimulation therapies, such as electroconvulsive therapy and vagus nerve stimulation.
Overall, the format of the Manual has been streamlined and blank space reduced. The organization of the clinical chapters now mirrors the Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5). Although some classical references remain, citations are thoroughly updated.
In this edition, we have moved toward a terminology that more accurately reflects the way healthcare professionals describe patient problems in the real world. This move eliminates the use of NANDA-I nursing diagnoses, which requires nurses to learn a second language in addition to the primary terms that are used by other healthcare providers. We hope that this approach will promote and support interprofessional collaboration for nursing students and nurses.
Acknowledgments
Thanks to my Elsevier family for coordinating and completing another successful project. Kudos go out to Yvonne Alexopoulos, senior content strategist, for providing feedback and supporting my ideas for this sixth edition. Yvonne is a brilliant person with thoughtprovoking comments along with a humorous take on thorny issues. As always, cheers go out to Lisa Newton, our content development manager. This is a woman who responds to emails within an hour, sends positive greetings, and adds a personal touch to nearly all of our communications.
As a senior content development specialist, Danielle Frazier moved the publishing process along while tirelessly re-uploading files to the electronic management system. Big thanks to Mike Sheets, project manager, for pulling all the details together, ensuring consistency, and producing a reader-friendly edition for students and clinical nurses.
Moving from NANDA-I based nursing care plans to a patient problem approach was a big move. Other nurse editors have pioneered and already adopted this method in their popular textbooks. I am especially grateful to editors Donna Ignatavicius and Pamela Swearingen for taking the lead in this endeavor and helping me through the process.
Finally, I'd like to acknowledge Elizabeth (Betsy - the real wizard) Varcarolis. Betsy developed a leading undergraduate psychiatric nursing textbook, Foundations of Psychiatric-Mental Health Nursing, and later added the Manual of Psychiatric Nursing Care Planning. Together, Betsy and I went on to introduce the popular Essentials of Psychiatric Mental Health Nursing, a more condensed version of Foundations. Countless psychiatric nursing students have read her words and been
prepared for the NCLEX based on her knowledge of this discipline. I am sincerely grateful to have been (and still am) Betsy's apprentice. I will always be indebted to her.
Peggy Halter
PART I
Foundations for Psychiatric Nursing Care
OUTLINE
Chapter
Chapter
Chapter
CHAPTER 1
The Nursing Process
The basis of psychiatric–mental health nursing is the therapeutic relationship. It is within this relationship that care is provided to address healthcare problems, both actual or potential. These problems occur in the context of or as the result of psychiatric disorders, also known as mental illness or mental disorders. A common language for nurses, physicians, social workers, psychologists, and other professionals who work in the mental health system facilitates patient care.
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the official publication of the American Psychiatric Association (APA) for categorizing medical diagnoses in the United States. The DSM provides clinicians, researchers, insurance companies, pharmaceutical firms, and policy makers with standard criteria for the classification of psychiatric disorders. Clinicians use this publication as a guide for planning care and evaluating patients' treatments.
First published in 1952, the current manual is the Diagnostic and Statistical Manual of Mental Disorders, fifth edition (DSM-5) (APA, 2013). The Manual of Psychiatric-Mental Health Nursing Care Planning uses the DSM-5 for organizing the order of clinical chapters and for describing psychiatric disorders.
The Nursing Process
The nursing process is a problem-solving process. It is the basic framework for nursing practice with patients who are experiencing psychiatric disorders or conditions. The National Council of State Boards of Nursing ([NCSBN] 2015, p. 3) defines the nursing process as “a scientific, clinical reasoning approach to client care that includes assessment, analysis, planning, implementation and evaluation.” The nursing process is fundamental to patient care and is the basis for this textbook.
Safety and quality care for patients are also prime directives for nurses and nursing education. The national initiative that is centered on patient safety and quality of care is known as Quality and Safety Education for Nurses (QSEN). QSEN competencies are integrated throughout this manual, and specific examples are highlighted along with each standard of practice. Box 1.1 provides a summary of the competencies.
Box 1.1
Quality and Safety Education for Nurses (QSEN) Competencies
Patient-centered care: Recognize the patient or designee as the source of control and full partner in providing compassionate and coordinated care based on respect for the patient's preferences, values, and needs.
Teamwork and collaboration: Function effectively within nursing and interprofessional teams, fostering open communication, mutual respect, and shared decision making to achieve quality patient care.
Evidence-based practice: Integrate best current evidence with
clinical expertise and patient/family preferences and values for delivery of optimal health care.
Quality improvement: Use data to monitor the outcomes of care processes and use improvement methods to design and test changes to continuously improve the quality and safety of health care systems.
Safety: Minimizes risk of harm to patients and providers through both system effectiveness and individual performance.
Informatics: Use information and technology to communicate, manage knowledge, mitigate error, and support decisionmaking.
QSEN Institute. (n.d.). QSEN competencies. Retrieved from http://qsen.org/competencies/pre-licensure-ksas
Assessment
Psychiatric–mental health registered nurses collect information that guides the plan of care. Assessment is an essential initial activity and it is also ongoing. The focus and type of information that is gathered is based on the patient's specific condition and by anticipating future needs.
Quality and Safety Standards (QSEN) Related to Assessment
• Patient-centered care: Elicit preferences, values, and expressed needs as part of the clinical interview.
• Informatics: Identify essential information that must be available in a common database to support patient care.
Patients with psychiatric disorders are not only found on behavioral health units. Symptoms such as depression, suicidal thoughts, anger, disorientation, delusions, and hallucinations are encountered in all settings. These settings include medical-surgical wards, obstetrical units, intensive care units, outpatient settings, extended-care facilities, emergency departments, and community centers. Psychiatric symptoms can also be the result of chemical imbalances, substance use, and disease. The assessment helps to identify and clearly articulate specific problems in the individual's life that are causing distress.
The assessment has several primary goals:
• Establish rapport.
• Elicit the patient's chief complaint (i.e., the
perception of the problem in the patient's own words).
• Review physical status and obtain baseline vital signs.
• Determine the impact of the disorder and symptoms on the patient's life (self-esteem, loss of intimacy, role functioning, change in family dynamics, lifestyle change, and employment issues).
• Identify risk factors that may affect safety (e.g., confusion, suicidal thoughts, or homicidal thoughts).
• Gather information related to previous illnesses, treatment, and hospitalizations.
• Identify psychosocial status (family relationships, social patterns, interests and abilities, stress factors, substance use, social supports).
• Complete a mental status examination.
It is helpful if the patient's family members, friends, and relatives participate during the data collection whenever possible. If a law enforcement agent brought the patient into the emergency department or crisis intervention unit, it is important for the nurse to understand what situation warranted police intervention.
Past medical and psychiatric history can supply valuable information. This is particularly important if the patient is experiencing psychosis, is withdrawn and mute, or is too agitated to
provide a history. Charts from previous hospitalizations or electronic medical records are extremely helpful. Laboratory reports also provide important information.
The use of a standardized nursing assessment tool facilitates the assessment process. Appendix A contains a patient-centered assessment tool. Most healthcare facilities provide patient assessments in either paper or electronic form. Although these tools are integral for gathering essential data, they can feel impersonal. With practice, nurses become proficient in gathering information in a less formal fashion, with the nurse clarifying, focusing, and exploring pertinent data with the patient. This method allows patients to state their perceptions in their own words and enables the nurse to observe a wide range of nonverbal behaviors. A personal style of interviewing congruent with the nurse's personality develops as comfort and experience increase. Box 1.2 presents the factors that are typically assessed.
What does the patient do in his or her spare time?
What sport, hobby, or leisure activity is the patient good at?
Medications
What medications does the patient take? How often? How much?
What herbal or over-the-counter drugs does the patient take? How often? How much?
What psychotropic drugs does the patient take or use? How often? How much?
How many drinks of alcohol does the patient take per day? Per week?
What recreational drugs does the patient take or use? How often? How much?
Does the patient identify the use of drugs as a problem?
Coping abilities
What does the patient do when he or she gets upset?
To whom can the patient talk?
What usually helps to relieve stress?
What did the patient try this time?
Issues for Which Referral May Be Indicated
Patients may be referred to social services and might need further investigation when planning long-term care. This is especially important in the case of severe mental illness, if any of the following issues are noted:
• Problems
with
primary support (death, illness, divorce, sexual or physical abuse,