Nursing tricks that make mental health nursing click

Therapeutic techniques: Open-ended questions ('Tell me what you're experiencing'), Reflection (mirror feelings back), Silence (therapeutic — allows processing), Clarification ('Help me understand...'), Empathy (not sympathy), Focusing, Summarizing. Non-therapeutic — AVOID: False reassurance ('You'll be fine soon'), Agreeing with delusions ('Yes, the government is after you'), Arguing with hallucinations, 'Why' questions (defensive), Giving advice ('You should...'), Minimizing ('It's not that bad'), Offering personal opinion. With psychosis: acknowledge feelings without validating delusion ('I understand you feel frightened, but I don't hear/see what you do').

Positive symptoms (excess of normal functions): hallucinations (auditory most common — 'voices'), delusions (fixed false beliefs — paranoid most common), disorganized thinking/speech (word salad, loose associations), disorganized behavior, catatonia. Negative symptoms (deficit of normal functions): flat affect, Alogia (poverty of speech), Avolition (lack of motivation), Anhedonia (inability to feel pleasure), social withdrawal — FLAT mnemonic. Antipsychotics: typical (haloperidol/Haldol — EPS side effects, good for positive symptoms), atypical (risperidone, olanzapine, quetiapine, clozapine — fewer EPS, better for negative, but metabolic effects). Clozapine: reserved for treatment-resistant — risk of agranulocytosis (weekly WBC monitoring).

Mild anxiety: increased awareness, can learn, slight tension. Nursing: use for health teaching. Moderate anxiety: narrowed focus, miss details, voice changes. Nursing: simple directions, focus attention. Severe anxiety: greatly reduced field of perception, cannot solve problems. Nursing: stay calm, walk with patient, direct simple commands ('Take a breath'). Panic: completely disorganized, feels like dying (MI-like), terror, possible depersonalization. Nursing: stay with patient (never leave), simple one-step directions, calm tone, quiet environment, medication (benzodiazepine). Never leave a panicking patient alone. Do NOT use long explanations during any anxiety higher than mild.

SIGECAPS (5+ symptoms for 2+ weeks for MDD): Sleep changes (insomnia or hypersomnia), Interest loss (anhedonia), Guilt/worthlessness, Energy loss/fatigue, Concentration impairment, Appetite/weight changes, Psychomotor changes (agitation or retardation), Suicidal ideation. Highest suicide risk: when antidepressants START working (energy returns before mood lifts — now has energy to act on plan). Monitor closely in first 2–4 weeks. Black box warning on SSRIs: increased suicidality in <25 year olds. SSRIs take 2–6 weeks for full effect — educate patient. Electroconvulsive therapy (ECT): effective for severe depression, not as a punishment.

Mania — DIGFAST: Distractibility, Impulsivity/Indiscretion, Grandiosity, Flight of ideas, Activity increased, Sleep decreased, Talkativeness (pressured speech). Hypomania: less severe, no psychosis, no hospitalization needed. Nursing during mania: high-calorie finger foods (too busy to sit for meals), simplify environment (reduce stimulation), matter-of-fact limit-setting on behavior, safety (poor impulse control → risky behaviors), monitor for exhaustion. Lithium: first-line mood stabilizer. Therapeutic 0.6–1.2 mEq/L. Toxicity: fine tremor, GI → coarse tremor, ataxia, seizure. Na+ depletion increases toxicity (dehydration, diuretics, sweating). Maintain adequate Na+ and fluid intake.

Cluster A ('Weird'): Paranoid (distrustful), Schizoid (isolated, no interest in relationships), Schizotypal (magical thinking, odd perceptions). Cluster B ('Wild'): Antisocial (no remorse, manipulative — do not be deceived, set limits consistently), Borderline (unstable relationships, self-harm, splitting — staff consistency essential), Histrionic (attention-seeking, dramatic), Narcissistic (grandiosity, lack empathy). Cluster C ('Worried'): Avoidant, Dependent, OCD. Borderline PD nursing: splitting (seeing staff as all-good or all-bad) — consistent approach by all staff, team communication essential. Self-harm: assess intent, safety plan, do NOT shame or dismiss.

Alcohol withdrawal timeline: 6–24 hrs — anxiety, tremors, diaphoresis. 24–48 hrs — seizures (risk — give benzodiazepines prophylactically). 48–72 hrs — Delirium Tremens (DTs): hallucinations (visual, tactile — 'bugs'), severe confusion, autonomic instability, hyperthermia, FATAL if untreated. CIWA-Ar scale: monitors severity, guides benzo dosing. Treatment: benzodiazepines (lorazepam, chlordiazepoxide), thiamine BEFORE glucose (Wernicke's encephalopathy prevention), hydration, seizure precautions. Opioid withdrawal: NOT life-threatening but very uncomfortable — flu-like symptoms, GI cramping, piloerection, myalgias, anxiety. Methadone or buprenorphine (Suboxone) for management.

Crisis: sudden overwhelming event disrupting equilibrium — person's usual coping mechanisms fail. Duration: acute crisis usually 4–6 weeks. Resolution: person returns to pre-crisis level, may develop new coping, or may deteriorate. NOT long-term therapy. Phases: 1) Assess safety (is there a suicide/homicide risk?), 2) Establish rapport, 3) Identify the problem (focus on precipitating event), 4) Assess coping (what has worked before?), 5) Plan interventions (what can they do NOW?), 6) Follow up. Balancing factors: realistic perception of event, adequate situational support, adequate coping mechanisms. Telephone crisis intervention: stay on line, get location, call emergency services if imminent danger.

Anorexia Nervosa: intense fear of weight gain, distorted body image, BMI <17.5. Medical: bradycardia, hypotension, hypothermia, lanugo (fine body hair — thermoregulation), amenorrhea, electrolyte imbalances (K+, Na+, phosphate), osteoporosis. Refeeding syndrome: rapid correction → severe hypophosphatemia → cardiac arrest (start nutrition slowly). Bulimia Nervosa: recurrent binge-purge cycles, normal or above-normal weight. Signs: dental enamel erosion (acid), parotid gland enlargement, Russell's sign (calluses on knuckles from self-induced vomiting), hypokalemia (most dangerous — cardiac dysrhythmias). Nursing: do NOT make weight the focus of conversation, supervise mealtimes, monitor electrolytes, therapeutic relationship, no shaming.

Voluntary admission: patient signs in, can request discharge at any time (may have 24–72 hr hold if danger). Involuntary commitment: 5150 (California) / 302 (Pennsylvania) / varies by state — criteria: danger to self, danger to others, or gravely disabled. 72-hour hold without hearing. Patient rights RETAINED: right to refuse treatment (except court-ordered), right to communicate, right to least restrictive environment, right to informed consent for procedures. Confidentiality: HIPAA — share only with treatment team. Exception: duty to warn (Tarasoff — if specific threat to specific person, must warn). Capacity vs competence: capacity = clinical (can patient understand?), competence = legal (court determination).

Milieu therapy: the therapeutic community — the entire environment (staff, patients, activities, rules) is the treatment. Principles: safety, structure (predictable schedule reduces anxiety), consistency (all staff respond the same way), community meetings (patient governance, voice), activity therapy (occupational, recreational, art). Admission safety check (contraband): sharps (razors, scissors, nail files), belts, shoelaces, drawstrings, electrical cords, glass containers, alcohol-based products (mouthwash, hand sanitizer — alcohol content), cell phones (privacy of other patients). Observation levels: general, every 15 minutes, every 5 minutes, 1:1 (constant), arm's length. Elopement precautions: patients may attempt to leave — know the facility's procedures.