Mental Health Nursing - Theoretical Foundations (Psychological and Nursing)
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| Definition: Model | A symbolic/pictorial representation of abstract concepts and relationships using minimal words.
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| Types of Models [2] | 1] Theoretical 2] Conceptual
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| Theories | Concepts of propositions that attempt to explain, predict, and master experienced phenomena.
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| Theories are never ________ but ________ and can be ________ but never ________ | discovered, invented, tested, proved.
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| Values of Theoretical Models in Psychiatry / Nursing | 1) rationalizes observed behavior 2) includes therapeutic treatment strategies 3) Defines patient and clinician roles 4) Organizes the data
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| Conceptual Models | Identify and clarify concepts, and propose relationships between concepts.
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| What are the 4 concepts in the Nursing Meta-Paradigm | Human, health, environment, nursing.
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| Freud's Contributions [5] | Pyschosexual stages of development, levels of awareness, personality structure, defense mechanisms, and psychodynamic process.
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| Freud: Psychosexual Stages of Development [5] | Oral, Anal, Phallic, Latency, Genital.
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| Psychosexual Stages of Development: 1] Oral | During weaning child uses mouth and tongue to deal with anxiety. Resolution: learns to trust and relate to environment. Fixation: involves smoking, alcoholism, drug addiction, nail biting, difficulty trusting.
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| Psychosexual Stages of Development: 2] Anal | Learns to control impulses (ego development) by delaying immediate gratification to gain a future goal. Fixation: become stubborn & anal retentive / anal expulsive, constipation, perfectionism, OCD.
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| Characteristics of Anal Retentiveness | stingy, rigid thought patterns, OCD.
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| Characteristics of Anal Expulsiveness | messy, destructive, cruel.
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| Psychosexual Stages of Development: 3] Phallic | Learns to identify with parent of same sex (develops Superego and solidifies ego) through resolution of Oedipus and Electra complexes. Fixation involves homosexuality, transsexuality, difficulty accepting authority.
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| Oedipus Complex | Boy unconcsciously wants to have sex with mother and kill father.
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| Electra Complex | Girl unconsciously wants to have sex with father, has penis envy.
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| Psychosexual Stages of Development: 4] Latency | Develops social skills and learns how to relate to others resulting in a sense of adequacy. Fixation: difficulty identifying with others and learning social skills --> inadequacy and inferiority i.e. lack of motivation in school or job.
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| Psychosexual Stages of Development: 5] Genital | Develops satisfying sexual & emotional relationships. Emancipation from parents results in formation of a strong personal identity and planning of life goals. Fixation results in: frigidity, impotence, and unsatisfactory relationships.
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| NCLEX: Nurse notes the client expresses the wish to be taken care of, and that the client often behaves in a helpless fashion. This client has needs related to what stage of psychosexual development (Latency, Phallic, Anal, or Oral)? | Latency stage. Rational: patient feels a sense of inadequacy AEB helplessness.
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| Frigidity | woman is unable to have an orgasm during sexual intercourse.
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| Freud: Levels of Awareness [3] | 1) Conscious, 2) Preconscious, 3) Unconscious
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| Levels of Awareness: 1] Conscious | "What we are aware of." Includes our perceptions, memories, thoughts, feelings, and fantasies.
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| Levels of Awareness: 2] Preconcsious | "Material that can be easily retrieved through minimal conscious effort."
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| Levels of Awareness: 3] Unconscious | "What we are unaware of and exerts a powerful effect on our conscious thoughts and feelings." This includes repressed memories, passions, urges.
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| Freud: Personality Structures [3] | Id, Ego, Superego
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| Personality Structures: Id | Illogical, operates on the pleasure principle. Acts on instincts and drives to fulfill needs. Where personality originates.
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| Pleasure principle | Id's desire to dispel tension and anxiety.
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| Personality Structures: Ego | Executive and mediator of the personality. Controls behavior by mediating conflicting demands of id, superego, and external environment. Reasonable, realistic, and logical to solving conflict. Produces defense mechanisms.
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| Ego: Defense Mechanisms | Prevents anxiety by inhibiting conscious awareness of threatening feelings. They operate subconsciously and "they deny, falsify, and distort reality to make it less threatening." i.e. denial, rationalization, projection, reaction formation.
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| Anxiety | response to increased tension.
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| Personality Structures: Superego | Perfectionist and ritualistic (OCD). Inhibits impulses of id. Operates on the morality principle; encourages ego to substitute realistic goals with moralistic goals. "Focuses on right and wrong."
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| What would happen if the id is too powerful? | Individual is impulsive.
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| What would happen if the superego is too powerful? | Individual is self critical and may suffer from feelings of inferiority.
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| Freud: Psychodynamic Process | Using tools of psychoanalysis for therapy. Includes analysis of dreams, countertransference, transference, free assocation, interpretation, and resistances.
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| Erik Erickson's contribution | Stages of Development, extends development through adulthood; culture and society greatly influence personality; may revisit stages at major life event points; key stage throughout life is identity versus role confusion.
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| Erikson's Stages of Development [1-4 of 8] | Infancy:trust vs mistrust (0-1.5), Early Childhood:autonomy vs shame&doubt (1.5-3), Late Chlidhood:initiative vs guilt (3-6), School Age:industry vs inferiority (6-12)... [more]
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| Erikson's Stages of Development Continued [5-8 of 8] | Adolescence:identity vs role confusion (12-20), Early Adulthood:intimacy vs isolation (20-35), Middle Adulthood:generativity vs self-absorption (35-65), Later Years:intgerity vs despair (65-death).
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| Infancy (0-1.5) Trust VS Mistrust: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] Trust in people, faith and hope about environment and future. 2]Difficulty relating with others; suspicion; trust-fear conflict; fear of future.
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| Early Childhood (1.5-3) Autonomy VS Shame & Doubt: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] Sense of self control and adequacy; will power. 2] Independence-fear conflict; severe feelings of doubt.
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| Late Childhood (3-6) Initiative VS Guilt: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] Ability to initiate one's own activities; sense of purpose. 2] aggression-fear conflict; sense of inadequacy or guilt.
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| School Age (6-12) Industry VS Inferiority: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] Competence; ability to work. 2] Sense of inferiority; difficulty learning and working.
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| Adolescence (12-20) Identity VS Role Confusion: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] Sense of personal identity; fidelity. 2] Identity confusion; submersion of identity in relationships or groups.
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| Early Adulthood (20-35) Intimacy VS Isolation: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] Ability to love deeply and commit oneself. 2] Emotional isolation; egocentricity.
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| Middle Adulthood (35-65) Generativity VS Self-absorption: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] ability to give and to care for others. 2] Inability to grow as a person; self-absorption.
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| Later Years (65-death) Integrity VS Despair: Examples of 1] Successful Resolution 2] Unsucessful Resolution | 1] Sense of integrity and fulfillment; willingness to face death; wisdom. 2] Dissatisfaction with life; denial of or despair over prospect of death.
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| NCLEX: Jim is a volunteer for Meals on Wheels. John is not and would rather not help anyone. These behaviors can be assessed as showing the difference between: Trust VS Mistrust, Intimacy VS Isolation, Generativity VS Self-Absorption | Generativity VS Self Absorption.
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| Sullivan, Harry Stack: Interpersonal Theory | Must address private, unseen mental processes; Personality is defined as behavior observed within interpersonal relationships; Goal of all behavior: to meet needs in interpersonal relationships... [more]
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| Interpersonal Theory continued | Sullivan states anxiety is from social insecurity. Coined the term "Security Operations: measures to reduce anxiety and increase self esteem."
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| Hildegard Peplau | Mother of psychiatric nursing.
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| Psychodynamic Model contributors include... | Freud - Erikson - Sullivan
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| Erik Berne's Contributions (Communication models) | Transactional Analysis, Ego States, Life stances, Analyze games and scripts as a tool.
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| Erik Berne: Life Stance | Basic beliefs about self and others, which are used to justify decisions and behavior. i.e. I state that "I don't know how to do this, will you show me" versus "I can't do this I'm useless." The latter states that they don't know yet how to do it.
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| Erik Berne: Ego States | Ego state - "a consistent pattern of feeling and experience directly related to a corresponding consistent pattern of behavior." This includes directly observable behavior related to three ego states: Parent, Child, Adult.
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| Erik Berne: Ego States - The Parent State | Formed by external events and influences in childhood; influenced by parents and authority figures; Typically embodied by phrases and attitudes i.e. 'how to', 'under no circumstances', 'always' and 'never forget', 'don't lie, cheat, steal.’
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| Erik Berne: Ego States - The Child | This is the seeing, hearing, feeling, and emotional body of data within each of us. When anger or despair dominates reason, the Child is in control.
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| Erik Berne: Ego States - The Adult | Our 'Adult' is our ability to think and determine action for ourselves, based on received data. Controls the child and parent states. Changing child and parent must be done within the adult state.
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| Erik Berne: Transactional Analysis | Identifies which ego state directed the stimulus and which ego state in the other person executed the response. Also one must not just look at what is being said but how it is being delivered.
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| Erik Berne: Types of Transactions [2] | 1] Complementary Transaction: the ego state sending the response is the same ego state that sent the stimulus. 2] Crossed Transaction: the ego state that sent the response is different than the ego state that sent the stimulus.
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| Humanistic Model | Maslow and Rogers
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| Maslow's Hierarchy of Needs | motives include deficiency needs essential to human survival, or higher level needs.
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| Carl Rogers: Person-Centered Approach | Have "uncond. + regard" (complete acceptance). Basis of therapy is centered on the "unique individual" client. Reflection; Client directs flow of therapy. Indiv. is capable of self-understanding, changing their attitude, and changing their behavior.
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| Existential Model: Frankl and Perls - Existential Therapeutic Process | Patient is guided by therapist to "accept self and to assume responsibility of behavior" rather than blaming the environment. Therapy focuses on self awareness and the idea that we are capable and free to choose our life experiences!
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| Existentialists view behavioral deviations arising from two things... | person being 1] "out of touch with himself and the environment" (feels sad, lonely, helpless) and person's lack of awareness and self-critical behavior causes 2] "self-imposed restrictions/limitations" in participating in satisfying relationships.
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| Existential Model: Frederick Perls - Gestalt Therapy | Aims for self-awareness, leading to self acceptance and responsibility of one's behaviors. Emphasis is in I.D. of thoughts and feelings i.e. writing/journaling; integration of the body and mind.
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| Existential Model: Viktor Frankl - Logotherapy | Use of paradoxical intention (reverse psychology) = do opposite of hyper-intended goal. i.e. Someone fears not getting a good night's sleep and tries too hard to sleep which then keeps him up at night!
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| Existential Model: William Glasser - Reality Therapy | Reconnect individuals with the people whom they've lost connection with. Done by focusing on here and now, what one does or thinks. Excuses (legitimate or not) are barriers to reconnecting.
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| Behavioral & Cognitive Behavioral: B.F. Skinner and Beck | Focuses on behaving and thinking over feeling.
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| B.F. Skinner - Operant Conditioning | Reinforcing behavior through manipulating reinforcers to elicit and strengthen it. Primary reinforcers are important for the behavior's survival/existence. Secondary reinforcers are "conditioned" by pairing with the primary reinforcer.
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| Operant Conditioning: an example of a secondary reinforcer… | I.e. food elicits salivation in dogs, paired with a conditioned reinforcer, the bell ringing, now bell elicits salivation.
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| Behavioral Model: Reciprocal Inhibition | A pleasant or anxiety-reducing state is paired with a stimulus that causes anxiety. This experience diminishes the anxiety response to the stimulus!
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| Behavioral Model: Positive Reinforcement | Adding a rewarding stimulus as a consequence of behavior, increasing the probability that the behavior will occur again. I.e. stars for doing well on homework.
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| Behavioral Model: Negative Reinforcement | Removing an aversive stimulus as a consequence of a behavior, increasing the probability it will occur again. i.e. Putting on sunglasses in glaring sunlight.
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| Behavioral Model: Assertiveness Training | Help people empower themselves / stand up for themselves. Uses "I statements" to help people express their feelings and reactions to others."
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| Behavioral Model: Aversion Therapy | Patient is exposed to a stimulus while simultaneously being subjected to some form of discomfort. This conditioning is intended to cause the patient to associate the stimulus with unpleasant sensations in order to stop the specific behavior.
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| Behavioral Model: Token Economy | Based on the principle of operant conditioning. Reinforcers are symbols or tokens that can be exchanged for other reinforcers. i.e. Tokens are given for good behavior and can be exchanged for sweets.
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| Cognitive Therapy: Marshall Linnehan - Dialectical Behavioral Therapy (DBT) | Treatment for Borderline Personality Disorder. Attempt to help client to see life in balance and not in black and white.
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| Cognitive Therapy: Marshall Linnehan - Dialectical Process of Treatment | A particular problematic behavior or event from past week is explored in detail, begsin with chain of events leading to event, xplore alt. sol. that might have been used, examine what kept client from using more adaptive solutions.
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| Cognitive Therapy: Aaron Beck - Cognitive Distortions | "Biased cognitions are faulty". Ways that our minds convince us of something that isn’t really true. Things we tell ourselves that sound rational and accurate, but aren’t really true and only serve to keep us feeling bad about ourselves.
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| Cognitive Therapy: Aaron Beck - Cognitive Restructuring | Changing cognitive distortions. Replaces one's irrational, counter-factual beliefs with more accurate and beneficial ones.
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| Cognitive Behavioral Model: Albert Ellis - Rational Emotive Therapy | Goal is to change irrational beliefs that reinforce dysfunctional behaviors! "Assumes that people are rational" and have the cognitive ability to think, decide, analyze, and do!
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| Cognitive Therapy: Roles of Patient & Therapist | HMO G SPACE = homework, measurements, open, goal oriented, short term, practical, active, collaborative, empirical.
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| Medical-Biological Model: Purpose | Understanding brain dysfunction and the action of psychotropic drugs. Concerned with the physiological disorders of the CNS. Keeps in mind that environment, social factors, and biology are interconnected!
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| What is a major focus of the Medical Biological Model? | Looking at brain structures and their linkage to symptoms of mentall illness. Abnormalities in brain structure or in its communication in specific locations can cause or contribute to neuro-psychiatric disorders.
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| During the 1990's the Medical-Biological model was greatly enhanced by the... | Era of the Brain.
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| What is important to realize about how Neurotransmitters work on the brain? | A neurotransmitter can have one effect on one part of the brain and different effects in another part of the brain.
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| Neurontransmitters in the Brain | Dopamine, Norepi, Melatonin, Serotonin.
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| Brain Imaging Techniques: Computed Tomography (CT) | 3D images using computed Xrays. Detects: Lesions, infarcts, aneuryms, cortical atrophy, ventrical enlargement.
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| Brain Imaging Techniques: Magnetic Resonance Imaging (MRI) | 3D visualization using a magnetic field & computed radio waves emitted by cells. Detects: edema, ischemia, infection, neoplasia, trauma, enlarged ventricles.
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| Brain Imaging Techniques: Positron Emission Tomography(PET) | Injected radioactive tracer travels to brain, concentrates in areas of high activity. Scanned images are relayed to a computer for 3D images.
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| Brain Imaging Techniques: Single Photon Emission Tomography (SPET) | Technique similar to PET but uses radio nuclides emitting gamma radiation. Detects O2 utilization, glucose metabolism, blood flow, neurotransmitter-receptor interaction.
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| Neurotransmitter Deficiency is related to | Deficient neurotransmitters or deficient receptors.
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| Neurotransmitter Excess is related to | Excess neurotransmitters or excess receptors.
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| NT: Dopamine | Increase: schizophrenia, mania; Decrease: depression, Parkinson's disease.
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| NT: Norepinephrine | Increase: mania, anxiety states, schizophrenia; Decrease: depression.
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| NT: Serotonin | Increase: anxiety states; Decrease: depression
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| NT: GABA | Increase: reduced anxiety; Decrease: anxiety disorders, schizophrenia.
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| NT: Acetylcholine | Increase: depression; Decrease: Parkinson's disease, Alzheimer's Disease, Huntingtons Chorea.
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| NT: Histamine | Decrease: depression.
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| NT: Review Part 1 of 2 | DEPRESSION --> Decrease dopamine/histamine/norepi/serotonin, Increase AcH. SCHIZOPHRENIA --> Increase Dopamine/Norepi, Decrease GABA. PARKINSON'S --> Decrease Dopa/ACH. MANIA --> Increase Dopa/Norepi.
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| NT: Review Part 2 of 2 | ANXIETY STATES --> Increaes Norepi/Serotonin. REDUCED ANXIETY --> Increased GABA. ANXIETY D/O --> Decreased GABA. ALZHEIMER'S --> Decrease ACH. HUNTINGTON'S CHOREA --> Decrease ACH.
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| NT: Depression | Decreased dopamine, histamine, norepinephrine, and serotonin. Increased ACH.
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| NT: Schizophrenia | Increased dopamine, norepinephrine. Decreased GABA.
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| NT: Parkinson's Disease | Decreased dopamine, ACH.
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| NT: Mania | Increased dopamine, norepinephrine.
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| NT: Anxiety States | Increased norepinephrine, serotonin.
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| NT: Anxiety Disorders | Decreased GABA.
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| NT: Reduction of Anxiety | Increased GABA.
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| NT: Alzheimer's Disease | Decreased ACH.
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| NT: Huntington's Chorea | Decreased ACH.
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| Medical-Biological Model and Genetics | Some mental illneses are genetically based. Several different genes in the mix. Non-genetic factors also contribute such as several genes on chromosomes may interact with the environment to cause schizophrenia.
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| Medical-Biological Model: Psychoneuroimmunology | Explores the interaction b/w the CNS, endocrine and the immune system. Psychosocial stressors may depress immune fxn.
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| Nursing Model: Meta-paradigm | Four Key terms - Human, Health, Environment, Nursing.
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| Nursing Model: Human | Wholistic; strives for homeostasis; dynamically interacts w/ environment; goal is optimal level of fxning.
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| Nursing Model: Health | Mental health is in constant change; concern is anywhere along the health-illness continuum.
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| Nursing Model: Environment | Dynamic; In constant interaction w/ human.
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| Nursing Model: Nursing | The diagnosis and treatment of human responses to actual or potential mental health problems; concerned with moving humans to their optimal level of fxning.
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| Nursing Model: Hildegard Peplau | Influenced by the work of Sullivan (Interpersonal Theory), Described the nurse-patient relationship. Believed that nurses could help patients with personal growth.
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| Hildegard Peplau: Psychological Mothering | Unconditional Acceptance, recognition of readiness, power shift from nurse to patient.
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| Hildegard Peplau: Interpersonal Nursing Roles | Stranger, resource person, teacher, leader, surrogate, counselor.
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| Hildegard Peplau: 4 stages of the Nurse-Patient Relationship | Pre-orientation Phase, Orientation Phase, Working Phase, Termination Phase.
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| Stages of the Nurse-Patient Relationship: Pre-Orientation Phase | Focuses on planning for the first interview with the patient. Data gathering is done prior to the interview.
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| Stages of the Nurse-Patient Relationship: Orientation Phase | Number of meetings varies, establish trust and boundaries (paramaters of relationship). Formal or informal contract, confidentiality is discusses, and also the terms of termination.
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| Stages of the Nurse-Patient Relationship: Working Phase | Maintain relationship, gather further data, promote problem solving. Facilitate behavioral change and overcome resistance behaviors. Evaluates problems & goals and define/revise as necessary. Promote practice & expression of alt. adaptive behaviors.
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| Stages of the Nurse-Patient Relationship: Termination Phase | Symptom relief, improved sense of identity, development of more adaptive behaviors, accomplishment of goals. Talk about any feelings of abandonment/loss felt by patient.
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| Therapeutic Communication is defined as... | A dynamic partnership between client and nurse that facilitates problem solving, change, learning, and growth.
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| Group Therapy: Definition of a group | Broadly, a group is 2 or more people who develop an interactive relationship.
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| Psychotherapeutic Group definition | trained leader/co-leaders establishes group for purpose of treating clients with psychiatric disorders.
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| Types of Groups [4] | 1] Content, 2] process-oriented, 3] mid-range groups, 4] educational groups.
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| Types of Groups: 1] Content | Focus on goals & tasks; define tasks and identify what needs to be accomplished; i.e. work groups.
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| Types of Groups: 2] Process-oriented | Relationship focus among members as well as communicaiton style & pattern. I.e. inpatient therapy or encounter groups.
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| Types of Groups: 3] Mid-range Groups | Combines tasks and processes. i.e. Support groups: Twelve-Step, Diabetes, Bereavement, Cardiac.
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| Types of Groups: 4] Educational Groups | Focus on teaching; i.e. health teaching, medication groups, or stress mgmt.
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| Eleven Elements of Therapeutic Groups | Altruism, universality, development of socializing skills, imitative behavior, interpersonal learning, imparting of info, corrective recapitulation of the primary family group, instill hope, group cohesiveness, catharsis, existential resolution.
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| Leaders of inpatient Psychotherapy Groups: Process Communication Guidelines | Advice or information sharing, clarification, confrontation, questioning, reflection, repetition or paraphrase, summarization, support.
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| Group Leader Roles [3] | 1] Starting - defines structure, size, composition, purpose. 2] Maintaining - facilitates communication, make sure they start and end on time. 3] Terminating - summarizes & gives feedback.
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| Group Member Roles [3] | 1] Task - keep group focused on main task 2] Maintenance - keep group together; helping members compromise 3] Individual - interfere with group function.
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| Phases of Group Development & Member Roles [4] | 1] Initial Phase, 2] Working Phase, 3] Mature Phase, 4] Termination Phase.
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| Phases of Group Development: 1] Initial Phase | Leader sets tone for respect, trust & confidentiality; members get to know one another & may offer each other advice.
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| Phases of Group Development: 2] Working Phase | Leader encourages cooperation and work with conflict; members jockey for power & control, challenge leader & begin to work together.
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| Phases of Group Development: 3] Mature Phase | Leader maintains focus on therapeutic goals of individual members; members develop functional norms & a sense of group identity, accept each other & help members achieve their goals.
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| Phases of Group Development: 4] Termination Phase | Leader summarizes the accomplishments of the group & the contributions of each member individually; members prepare for separation & help each other prepare for the future
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| Phases of Group Development: 3] Mature Phase | Leader maintains focus on therapeutic goals of individual members; members develop functional norms & a sense of group identity, accept each other & help members achieve their goals.
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| Phases of Group Development: 4] Termination Phase | Leader summarizes the accomplishments of the group & the contributions of each member individually; members prepare for separation & help each other prepare for the future
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