A 74-year-old African American woman, Ms. Richardson, was brought to the hospital emergency room by the police. ?She is unkempt, dirty, and foul-smelling. ?She does
A 74-year-old African American woman, Ms. Richardson, was brought to the hospital emergency room by the police. She is unkempt, dirty, and foul-smelling. She does not look at the interviewer and is apparently confused and unresponsive to most of his questions. She knows her name and address, but not the day of the month. She is unable to describe the events that led to her admission.
The police reported that they were called by neighbors because Ms. Richardson had been wandering around the neighborhood and not taking care of herself. The medical center mobile crisis unit went to her house twice but could not get in and presumed she was not home. Finally, the police came and broke into the apartment, where they were met by a snarling German shepherd. They shot the dog with a tranquilizing gun and then found Ms. Richardson hiding in the corner, wearing nothing but a bra. The apartment was filthy, the floor littered with dog feces. The police found a gun, which they took into custody. The following day, while Ms. Richardson was awaiting transfer to a medical unit for treatment of her out-of-control diabetes, the psychiatric provider attempted to interview her. Her facial expression was still mostly unresponsive, and she still didn’t know the month and couldn’t say what hospital she was in. She reported that the neighbors had called the police because she was “sick,” and indeed she had felt sick and weak, with pains in her shoulder; in addition, she had not eaten for 3 days. She remembered that the police had shot her dog with a tranquilizer and said the dog was now in “the shop” and would be returned to her when she got home. She refused to give the name of a neighbor who was a friend, saying, “he’s got enough troubles of his own.” She denied ever being in a psychiatric hospital or hearing voices but acknowledged that she had at one point seen a psychiatrist “near downtown” because she couldn’t sleep. He had prescribed medication that was too strong, so she didn’t take it. She didn’t remember the name, so the interviewer asked if it was Thorazine. She said no, it was “allal.” ‘Haldol?”, ask the interviewer. She nodded.
The interviewer was convinced that was the drug, but other observers thought she might have said yes to anything that sounded remotely like it, such as “Elavil.” When asked about the gun, she denied, with some annoyance, that it was real and said it was a toy gun that had been brought to the house by her brother, who had died 8 years ago. She was still feeling weak and sick, complained of pain in her shoulder, and apparently had trouble swallowing. She did manage to smile as the team left her bedside.
Answer the following using APA 7, and 500 words:
Remember to answer these questions from your textbooks and clinical guidelines to create your evidence-based treatment plan. At all times, explain your answers.
- Summarize the clinical case including the significant subjective and objective data.
- Generate a primary and two differential diagnoses. Use the DSM5 to support the assessment. Include the DSM5 and ICD 10 codes.
- Discuss a pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
- Discuss non-pharmacological treatment would you prescribe? Use the clinical guidelines to support the rationale for this treatment.
- Describe a health promotion intervention that would be appropriate for this patient.
ADVANCED PRACTICE PSYCHIATRIC NURSING
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Kathleen R. Tusaie, PhD, PMHCNS/NP-BC, is a professor at the University of Akron and has been in private practice since 1988. Dr. Tusaie is certified as a psychiatric-mental health clinical nurse specialist and psychiatric nurse practitioner by the American Nurse Credentialing Center. She holds certificates in advanced pharmacology, multicultural nursing, eye movement desensitization and reprocessing (EMDR), psychoneuroimumunology, brief psychotherapy, cognitive behavioral therapy (CBT), clinical hypnosis, and Bowen family therapy. In addition to the University of Akron, she has taught at the University of Pittsburgh and Pennsylvania State University School of Nursing. Her research has focused on the concept of resilience and she has published and presented internationally. Dr. Tusaie has been the principal investigator or co-principal investigator in five funded research projects and has received many awards and honors.
Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN, is Elizabeth Brooks Ford Professor of Nursing, Frances Payne Bolton School of Nursing, Case Western Reserve University (CWRU) in Cleveland, Ohio, where she was dean from 1982 through 1997. She holds an adjunct position as professor, Department of Geriatrics, Mount Sinai School of Medicine, New York, New York. She earned a BSN (Georgetown University), an MS in psychiatric-mental health nursing (the Ohio State University, Columbus), a PhD in nursing (New York University), and an MBA from CWRU. Dr. Fitzpatrick has received numerous honors and awards; she was elected a fellow in the American Academy of Nursing in 1981 and a fellow in the National Academies of Practice in 1996. She received the American Journal of Nursing Book of the Year Award 18 times. Dr. Fitzpatrick is widely published in nursing and health care literature. She served as co-editor of the Annual Review of Nursing Research series, volumes 1–26; she edits the journals Applied Nursing Research, Archives of Psychiatric Nursing, and Nursing Education Perspectives, the official journal of the National League for Nursing. She has published several books with Springer Publishing Company, including three editions of the classic Encyclopedia of Nursing Research (ENR).
3
ADVANCED PRACTICE PSYCHIATRIC NURSING
Integrating Psychotherapy, Psychopharmacology, and Complementary and Alternative Approaches Across the Life Span
Second Edition
Kathleen R. Tusaie, PhD, PMHCNS/NP-BC Joyce J. Fitzpatrick, PhD, MBA, RN, FAAN
Editors
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Library of Congress Cataloging-in-Publication Data
Names: Tusaie, Kathleen R., editor. | Fitzpatrick, Joyce J., 1944– editor. Title: Advanced practice psychiatric nursing : integrating psychotherapy, psychopharmacology, and
complementary and alternative approaches across the life span / Kathleen R. Tusaie, Joyce J. Fitzpatrick, editors.
Other titles: Advanced practice psychiatric nursing (Tusaie) Description: Second edition. | New York, NY : Springer Publishing Company, LLC, [2017] |
Includes bibliographical references and index. Identifiers: LCCN 2016020157 | ISBN 9780826132536 | ISBN 9780826132529 (e-book) | ISBN
9780826134448 (instructors PowerPoints)
5
Subjects: | MESH: Psychiatric Nursing—methods | Advanced Practice Nursing—methods | Mental Disorders—nursing
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CONTENTS
Contributors Foreword to the First Edition
Grayce M. Sills, PhD, RN, FAAN Preface Share Advanced Practice Psychiatric Nursing: Integrating Psychotherapy,
Psychopharmacology, and Complementary and Alternative Approaches Across the Life Span, Second Edition
SECTION I. THE DYNAMIC NATURE OF ADVANCED PRACTICE PSYCHIATRIC-MENTAL HEALTH NURSING
1. Theoretical Understandings and Evidence Base for Practice Joyce J. Fitzpatrick Overview Commonly Used Theories in Psychiatric-Mental Health Practice
Psychodynamic Theories Cognitive Theories Behavioral Theories Psychosocial Theories Developmental Theories Interpersonal Theories Humanistic Theories Biological Theories General Systems Theory Change Theories The Theory of Reasoned Action and Planned Behavior Transtheoretical Model
Nursing Theories Specific to Psychiatric Nursing Interrelationship Between Theory and Research Distinctions Between Research and Evidence-Based Practice
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Summary
2. Shared Decision Making: Concordance Between Psychiatric-Mental Health Advanced Practice Registered Nurse and Client Austyn Snowden and Kathleen R. Tusaie Overview Advanced Psychiatric-Mental Health Nursing Practice Concordance
Background Knowledge Health Beliefs Collaboration
Improving Concordance Knowledge Health Beliefs Collaboration
Summary Resources
SECTION II. FOUNDATIONS FOR INTEGRATIVE PRACTICE
3. Synergy of Integrative Treatment Kathleen R. Tusaie Overview Rationale for Integrative Treatment Thinking About the World Transdiagnostic Syndromes Effects of Integrative Treatment Continuum of Treatment Interventions
4. Overview of Psychotherapy Kathleen R. Delaney and Ricardo Broach Overview Psychodynamic Therapy
Applications of Dynamic Principles in Therapy Dynamic Supportive Therapy
Cognitive Therapy Interpersonal Therapy
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Behavioral Therapy Theoretical Basis Underlying Change Techniques of Behavioral Therapy Positive Psychology
Summary
5. Overview of Psychopharmacology Debbie Steele, Joan S. Grant, and Norman L. Keltner Overview Neuronal Transmission
Dopamine Norepinephrine Serotonin GABA Glutamate Acetylcholine
Psychotropic Drugs History of Antipsychotics Typical Antipsychotics Adverse Effects and Typical Antipsychotics Extrapyramidal Side Effects Hyperprolactinemia Increased Negative Symptoms Neuroleptic Malignant Syndrome Atypical Antipsychotics Individual Atypical Antipsychotics Adverse Effects and Atypical Antipsychotics
Cardiometabolic Syndrome New Developments Antidepressants Selective Monoamine Reuptake Inhibitors Anti-Anxiety Agents Bipolar Disorder Medications
Summary Psychopharmacogenetics
6. Overview of Complementary/Integrative Approaches Kathleen R. Tusaie and Rosanne Radziewicz
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Overview Types of Complementary/Integrative Interventions
Biologically Based Practices Specific Herbs and Nutrients Commonly Suggested for Mental Health Mind–Body Interventions Relaxation Response Manipulative and Body-Based Practices Energy Work
Practice Guidelines Resources
7. Stages of Treatment Kathleen R. Tusaie Overview Techniques for Developing Therapeutic Relationships
Instilling Hope Communication Strategies for Following Up on Leads and Instilling
Hope Client Resources PMH-APRN Resources Skill and Knowledge
Stages of Treatment Assessment and Diagnosis Transitioning to New Topics Personal Developmental History Values or Aspirations Using Self-Report Questionnaires Synthesizing Information Risk Formulation Diagnosis (DSM) Case Formulation Advantages and Disadvantages of Split Treatment Delivery (More Than
One Provider) Comparison of Individual and Group Therapy Further Testing or Referrals Acute Treatment Therapeutic Communication Techniques Stabilization/Maintenance
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Termination Appendix 7.1 Genogram
SECTION III. INTEGRATIVE MANAGEMENT OF SPECIFIC SYNDROMES
8. Integrative Management of Disordered Mood Kathleen R. Tusaie Overview Spectrum of Moods
Etiology Diathesis Stress Summary
Shared Decision Making or Achieving Concordance Bearing Witness to Suffering Assessment Suicidal and Homicidal Thoughts
Diagnosis Symptoms and Questionnaires
History of Mood Disorder Symptoms Self-Evaluation Comorbidity Insomnia
Collaborative Case Conceptualization Expected Outcomes Treatment
Response Initiating Treatment Determine Severity of Symptoms and Level of Risk Low Severity/Low Risk Complementary/Alternative Approaches Moderate Severity and Risk
Transcranial Magnetic Stimulation Psychotherapy High Level of Severity of Symptoms and Risk Electroconvulsive Therapy
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Vagal Nerve Stimulation Acute Follow-Up or Continuation Managing Side Effects Pharmacotherapy Maintenance Primary Prevention
Resources
9. Integrative Management of Anxiety-Related Conditions Kathryn Johnson and Beth Phoenix Overview Anxiety-Related Conditions The Anxiety Cycle Physiological Responses
Cognition Behavioral Responses
Etiology of Anxiety and Anxiety-Related Disorders Psychological Views of Anxiety Physiological Factors Genetic Factors Prevalence and Impact of Anxiety Conditions Types of Anxiety Conditions
Assessment Chief Complaint Historical Data Mental State Examination
Concordance and Treatment Planning Expected Outcomes Treatment Initiation Psychotherapy
Cognitive Behavioral Therapies Other Psychotherapies Eye Movement Desensitization and Reprocessing
Medications Benzodiazepines Antidepressants Azapirones Noradrenergic Agents
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Anticonvulsants Second-Generation Antipsychotics
Client Self-Management Herbal Remedies and Nutritional Supplements Bibliotherapy and Computer-Assisted CBT Physical Methods
Special Considerations: Prevention Resources
10. Integrative Management of Psychotic Symptoms Marianne Tarraza and Linda Jacobson Overview Incidence Prevalence History Etiology Assessment Stages of Schizophrenia
Clinical Assessment Assessment Scales
Concordance and Shared Decision Making Expected Outcomes
Suicide and Psychosis Diagnosis
Differential Diagnoses Cultural Considerations Families
Treatment Medications
Treatment Resistance or Inadequate Response Managing Side Effects
Neuroleptic Malignant Syndrome Serotonin Syndrome Extrapyramidal Side Effects Tardive Dyskinesia Abnormal Involuntary Movement Scale Other Side Effects to Consider Concerns in Prescribing
Treatment: Psychosocial and Others Patient Education
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Mind–Body Medicine and Schizophrenia Summary Resources
11. Integrative Management of Sleep Disturbances Carol Enderlin, Martha E. Kuhlmann, Melodee Harris, Matthew Hadley, Arlene Sullivan, Karen M. Rose, Anita Mitchell, and Ellyn E. Matthews Overview Normal Sleep Architecture Sleep Across the Life Span
Newborn Period Infancy Toddlerhood School Age Adolescence Young and Middle-Aged Adulthood Older Adulthood
Familial and Genetic Implications Sleep Disorders Sleep History and Physical Assessment General Sleep History Focused Physical Assessment Analysis of Sleep Symptoms and Specialized Sleep Screening Specialized Sleep Screening Tools
Regulation of Sleep Sleep and Comorbid Psychiatric Disorders Sleep and Comorbid Medical Disorders Nursing Decision Trees Shared Decision Making and Collaborative Treatment Planning
Treatment Nonpharmacological Treatment of Sleep Disorders Complementary and Alternative Medicine Modalities
Long-Term Management of Sleep Disorders Circadian Rhythm Disorders Narcolepsy Insomnia REM Behavior Disorder Central and Mixed Sleep Apneas
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Obstructive Sleep Apnea RLS and PLM of Sleep Age-Related Sleep Implications
Summary Resources
12. Integrative Management of Disordered Eating Deborah B. Fahs, Robert Krause, and Kathleen R. Tusaie Overview Bulimia Nervosa
Epidemiology Etiology of BN Assessment Concordance Expected Outcomes Treatment Initiation and Acute Follow-Up Maintenance Pharmacotherapy of BN Prognosis Bulimia Nervosa Special Considerations
Anorexia Nervosa Assessment Etiology Distinguishing Between Causes and Effects of AN Sociological and Psychological Factors Expected Outcomes Special Considerations
Obesity Relationship Between Psychiatric Disorders and Obesity Etiology Concordance Assessment Expected Outcomes Treatment Initiation and Acute Follow-Up Pharmacological Interventions Maintenance/Termination
Resources
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13. Integrative Management of Disordered Cognition Anita Thompson Heisterman Overview Classification of Neurocognitive Disorders General Principles for Assessment of Older Adults Delirium
Assessment of Delirium Screening Instruments for Delirium Shared Decision Making/Achieving Concordance Outcomes Treatment of Delirium
Mild Neurocognitive Disorders Major Neurocognitive Disorders
Etiology Alzheimer’s Disease Vascular Disease Lewy Body Disease Parkinson’s Disease Frontotemporal Lobar Degeneration Other Forms of Neurocognitive Disorders Substance-Induced Major Cognitive Disorder—Amnestic Confabulatory
Type Clinical Signs and Course of Alzheimer’s Disease (as the Prototype
Neurocognitive Disorder) Early Stage Intermediate Stage Late Stage Shared Decision Making/Achieving Concordance Assessment History Physical Mental Status Examination Diagnostic Tools Differential Diagnosis Expected Outcomes Treatment Acute Follow-Up and Maintenance Treatment
Summary
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Resources
14. Integrative Management of Disordered Attention Marianne Tarraza and Lisa Barry Overview Attention Deficit Disorder or Attention Deficit Hyperactivity Disorder
Prevalence Etiology/Risk Factors Comorbidity
Autism Spectrum Etiology
ADHD and the Brain ADHD and the Role of Neurotransmitters ADHD and Genetics ADHD and Environment Assessment
Broadband Assessments Narrowband Assessments Assessment of Medication Adverse Effect Management
Diagnosis Psychiatric Comorbidities Medical Comorbidities Achieving Concordance Expected Outcomes
Treatment Initiation Nonpharmacological Treatments
Behavior Modification Cognitive Behavioral Therapy Individual, Family, and Group Therapy
Complementary and Alternative Therapies Nutritional Interventions Herbal and Natural Health Products Vitamins and Minerals Caffeine Homeopathy Exercise Massage, Meditation, and Yoga
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Acupuncture Osteopathic Manipulative Treatment (OMT) and Chiropractic
Manipulation Electroencephalographic Biofeedback Playing in Green Spaces
Pharmacological Treatments Stimulants Response Nonstimulants Follow-Up/Maintenance Managing Side Effects Additional Considerations
Cultural Considerations Autism Spectrum Disorder
Prevalence Etiology/Risk Factors Symptoms Treatment Management Special Populations
Resources
15. Integrated Management of Self-Directed Injury Ann M. Mitchell, Irene Kane, Kirstyn M. Kameg, Kirsti Hetager Stark, and Brayden Kameg Overview Definitions Epidemiology The CASE Approach to NSSIB/SSIB Assessment
Step 1 Step 2 Step 3 Step 4
Assessment Within the CASE Approach Assessment Instruments Relationship Building During Assessment Integration of Therapeutic Models
Cognitive Behavioral Therapy
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Dialectical Behavioral Therapy Motivational Interviewing Mindfulness-Based Cognitive Therapy Future-Oriented Group Training Therapy Pharmacological Management
Pulling It Together: CASE Approach Care Plan Continuing Care for the Self-Injurious Individual
Special Considerations Comorbidities Autoerotic Asphyxiation (Sexual Masochism Disorder With
Asphyxiophilia) Resources
16. Integrated Management of Other-Directed Violence Marla McCall Overview Intimate Partner Violence Child Abuse Elder Abuse Rape Human Trafficking Bullying Violence Toward Health Care Professionals (HCPs)
Types of Violence Toward Health Professionals Horizontal and Vertical Violence Within Nursing
Effects of Violence on Survivors Sequelae of IPV Office Safety Policies
Assessment Migrant and Refugee Populations HCPs are at High Risk Psychiatric Clinicians Others Most at Risk for Victimization
Assessment of Individual Potential for Violence Rule Out Medical Reasons First, Then Assess Psychiatric Factors
Risk Assessment Questionnaires Inpatient Outpatient
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Etiology: Patient Populations at Risk for Perpetrating Violence General Diagnostic Categories Delusional Disorders CD and Antisocial Personality Disorder (APD) Substance Abuse, Mental Illness, and APD Low IQ, Head Injury, Chemical Exposures as Risk Factors for Violence History of Traumatic Childhood Experiences Neuroendocrine, Genetic, and Hereditary Factors
Expected Outcomes Concordance in Management of Incidents of Violence
Treatment Initiation, Acute Phase of Violence Acute Agitation
Follw-Up: Acute Dystonia, Neuroleptic Malignant Syndrome, Allergy Maintenance Interventions
Antiepileptic Drugs and Other Mood Stabilizers Antidepressants General Medication Considerations
Managing Side Effects Laboratory Studies Extrapyramidal Side Effects Blood Dyscrasias Anticonvulsant Hypersensitivity Syndrome SIADH, Hyponatremia, Acidosis Weight Gain, Hyperglycemia, Metabolic Syndrome, Cardiac Events Elevated Prolactin Level, Hypothyroidism, Renal Problems, Sexual
Dysfunction Movement Disorders
Dietary Measures, Caffeine, Sugar, Vitamins, and Supplements Caffeine Micronutrients and Supplements Refined Foods and Sugar
Exercise, Stress Management, Eastern Healing Environmental, Cultural, and Milieu Management Longer Term CBTs and Group Interventions
Pediatric Considerations CBT and DBT Pediatric Clinical Case Study CBT for Perpetrators
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Group Mobilization and Social Attitude Transformation Cognitive Therapy and APD Therapy Interventions for Parents Therapeutic Interventions for Children and Adolescents Complementary/Alternative Therapies Treatment for PTSD Therapeutic Milieu Treatment for the Developmentally Delayed Violent
Person Training of Psychiatric Personnel in Violence Management Basic Elements of Violence-Prevention Training
Know the Physical Environment and Institutional Policies Critical Incident Stress Management Versus Occupational Health
Legal Issues Legal Responsibilities When Legal Action Rather Than Further Treatment Must Be Pursued
Providing Culturally Competent Care Summary Resources
17. Integrative Management of Disordered Impulse Control Lisa L. Salser Overview The Process of Impulse Control
Psychoanalytical Perspective Neuroscience/Developmental Perspective Cognitive/Behavioral Perspective
Measurement of Impulsivity Impulsivity Versus Compulsivity Prevalence and Impact of Impulse Control Problems Types of Impulse Control Disorders
Oppositional Defiant Disorder Conduct Disorder Pyromania Kleptomania Intermittent Explosive Disorder Antisocial Personality Disorder
Summary Resources
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SECTION IV. SPECIAL CONSIDERATIONS
18. Co-Occurring Substance Misuse and Psychiatric Syndromes Faye Gary, Rita A. Hanuschock, and Ruzica Conic Overview Epidemiology Theory of Addiction
Dopamine Theory Gateway Hypothesis Common Liability to Addiction Genetic Factors Environmental Factors Physiological Consequences
Establishing a Diagnosis of SUD Substances of Abuse
Ethyl Alcohol Nicotine Sedatives Stimulants Hallucinogens Narcotics
Determining Appropriate Levels of Care for Treatment of SUDs Outpatient Treatment Intensive Outpatient Programs (IOPs) Partial Hospital Programs Residential Services Continuing Care Treatment-Resistant Patients
Taking a Patient History for Individuals With Suspected Substance Use Physical Findings in Patients With Substance Use Laboratory Testing and Findings
Breath Testing Urine Testing Sweat Testing Oral Fluid Testing Blood Testing Hair Testing
22
Special Populations Adolescents Elderly Health Care Workers Native Americans
Summary
19. Medical Problems and Psychiatric Syndromes Marianne Tarraza Overview Impact of Comorbid Psychiatric Syndromes and Medical Illness
What Is the Cost and Mortality Burden of Comorbidities? Assessment
Diagnostic Approach Concordance
Effective Communication Between the Medical Team and the Mental Health Team
Depressive Disorders Depression and Heart Disease Depression and Diabetes Mellitus Depression and HIV Infection/AIDS Depression and Asthma
Anxiety Disorders Anxiety Disorders and Diabetes Anxiety and Asthma
Bipolar Disorder Bipolar Disorder and Migraine Bipolar Disorder and Velocardiofacial Syndrome Bipolar Disorder and Multiple Sclerosis Bipolar Disorder and Asthma Bipolar Disorder and Diabetes Mellitus Bipolar Disorder and Polycystic Ovarian Syndrome Bipolar Disorder and Obesity
Schizophrenia Schizophrenia and CVD Schizophrenia and Diabetes
Parkinson’s Disease Medical and Psychiatric Comorbidities Related to Pharmacology
23
The Impact of Common Medications Causing Psychiatric Syndromes The Impact of Common Psychiatric Medications Causing Medical
Comorbidity Overview of Treatment
Use of Appropriate Medical and Mental Health Screening Tools at First Encounters
Evaluate for Underlying Medical Conditions That May Be Causing Psychiatric Syndromes and Mental Health Conditions That May Be Causing Medical Problems
Use of Medication Reconciliation at All Encounters Appropriate and Timely Referrals Between Caregivers Holistic Approach
Management Summary
20. Pregnancy During Psychiatric Syndromes Jennifer L. Smith and Carrie R. Cichocki Overview Concordance Principles of Fetal Development and Pharmacology Anxiety Disorders Posttraumatic Stress Disorder Obsessive-Compulsive Disorder Depression Bipolar Disorder Schizophrenia Substance Use Disorders Other Considerations for Treatment in the Perinatal Period
Perinatal Loss and Grief Intimate Partner Violence Hyperemesis Gravidarum
Special Considerations in the Postpartum Period Lactation
Summary
21. Forensic Issues and Psychiatric Syndromes Jeffrey S. Jones Overview Corrections
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Interpersonal Process Concept of Nursing Care and the Criminal Boundaries Therapy
Antisocial Personality Disorder Malingering The Diagnostic Interview Follow-Up Work Assessments Etiology
True Severe and Persistent Mental Illness Malingering Antisocial Personality Disorder Concordance (Shared Decision Making, Planning With Client) Expected Outcomes Treatment Initiation Treatment of Severe and Persistent Chronic Mental Illness Treatment of Malingering Treatment of APD Adjustment Disorders
Special Considerations Summary
SECTION V. MAINTAINING COMPETENCE AND QUALITY
22. QSEN Competencies: Application to Advanced Practice Mental Health Nursing Susan E. Phillips, Mary A. Dolansky, and Denise Mathews Overview Safety Patient-Centered Care Teamwork and Collaboration Evidence-Based Practice Quality Improvement Informatics A Systems Approach to Meeting QSEN Competencies
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23. Telehealth Patti G. Rodgers Overview Technology Guidelines Telemental Health Models of Care Practice Guidelines and Technical Standards The Need fo
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