Personal Space Boundaries: Clinical Applications in Psychiatric Mental Health Nursing

topic . Theory of personal space boundaries (PSB) and its application to clinical psychiatric nursing.
purpose . To provide a nursing perspective of interventions that incorporate the interactive effects of cognition, affect, behavior, and spirituality on human experience and behavior.
source . Theory of PSB developed by the author.
conclusion . Understanding PSB allows for more effective nursing interventions.     

Informal Role Expansion in Australian Mental Health Nursing

PURPOSE.  This study aims to determine the extent to which community mental health nurses are currently practicing beyond the traditional scope of nursing practice .
DESIGN AND METHODS.  A self-administered questionnaire was distributed to community mental health nurses in Victoria, Australia.
FINDINGS.  The majority of participants reported routine involvement in practices that would normally be considered beyond the scope of nursing practice, such as prescribing, ordering diagnostic tests, and referral to specialists.
PRACTICE IMPLICATIONS.  The extent to which the current mental health service system is dependent upon nurses transgressing professional and legal boundaries warrants further study. Psychiatrists and community mental health nurses need to work collaboratively to understand their respective knowledge and skills and to be clear about how they take responsibility for client care.     

Ombudsman: A New Role for Advanced Practice Nurses in Psychiatric-Mental Health Nursing

topic . The role of ombudsman for advanced practice nurses in psychiatric mental health nursing.
purpose . To describe the role of ombudsman and its fit with nursing as seen in the Price Spratlen Ombudsing Model.
source . The author's own experiences as both an advanced practice nurse and an ombudsman.
conclusion . Because of downsizing, reorganization, and a general trend toward mutual distrust in large organizations, being an ombudsman has been named one of the "25 hottest careers." Advanced practice nurses in psychiatric mental health nursing, by virtue of their knowledge of interpersonal, preventive, and systems theories, are in a unique position to fill this role.     

Characteristics of the demented living in different settings in Sweden

Introduction — The aim of this paper is to describe elderly people living in different care settings in Sweden according to prevalence of dementia, ADL functions, psychiatric symptoms, behavioural symptoms and workload imposed on the staff.
Material & methods — In total 842 persons living in different settings (nursing homes, homes for the aged, service houses and group-livings) has been investigated. The MDDAS scale has been used to measure motor functions, vision, hearing, speech, ADL functions, behavioural disturbances, psychiatric symptoms and workload imposed on the staff.
Results — Probands cared for in different settings differ considerably as to prevalence of dementia, ADL functions, behaviour and psychiatric symptoms. Those living in nursing homes were most impaired and imposed the heaviest workload on the staff. The study has also shown that the nursing load is increasing rapidly in the homes for the aged.     

Mental and physical capacity and consumption of neuroleptic drugs in residents of nursing homes

The mental and physical capacity of all persons living permanently in a nursing home in Bergen were estimated and their neuroleptic drug consumption and duration of stay were registered. Fifty-one per cent were severely and 14% moderately mentally impaired. Eighty-seven per cent demanded more extensive nursing care. Physical dependence was significantly associated with mental decline, but not with age. 32.6% received regularly neuroleptic medication, which was most common among restless and wandering residents. Dosage fell with increasing age and decreasing ability to perform personal hygiene.     

Bibliotherapy and Beyond

topic . Using literature and television to promote mental health
purpose . To expand readers'awareness of how literature can be used therapeutically
source . The author's personal experience hosting a TV program entitled, "Best Books in Town"
conclusions . Discussing literature can promote emotional catharsis, active problem solving, and personal insight in those who chose to participate.     

Are nursing home patients with dementia diagnosis at increased risk for inadequate pain treatment?

BACKGROUND: Mentally impaired and demented nursing home patients are at increased risk of undertreatment for pain. We wanted to examine pain assessment and complaints and pain treatment of nursing home patients according to mental state, and with special regard to treatment of patients with dementia diagnosis and cognitively impaired patients who did not have a dementia diagnosis. METHODS: Cross sectional study from three nursing homes in Bergen, Norway including 125 persons (median age 84 years), living permanently in a nursing home. Diagnoses and prescribed and administered analgesic drugs were recorded. An experienced nurse interviewed nurses in charge and patients regarding presence of pain during the last week. Patients who were able to answer whether they had experienced pain during the last week were categorised as communicative. Cognitive function was assessed by means of the Abbreviated Mental Test. RESULTS: Seventeen percent of the patients were cognitively intact, 30% cognitively impaired and 54% had a dementia diagnosis. Forty-seven percent of communicative patients complained of pain, nurses reported pain in 67% patients. Twenty-nine percent of the patients had received scheduled analgesics during the last week, cognitively intact patients 38%, cognitively impaired 30%, demented 25% (p = 0.53). Twenty percent were given analgesics PRN: cognitively intact patients 33%, cognitively impaired 27%, demented 12% (p = 0.05). Logistic regression analyses revealed that patients with dementia diagnosis were less likely to receive PRN medication [Adjusted odds ratio (AOR) 0.22 95% confidence interval (CI) 0.06-0.76] compared to mentally impaired patients. Regarding scheduled medication there was no difference between the groups. Nurses' opinion of pain was a significant factor for receiving analgesic drugs, scheduled AOR 3.95 95% CI 1.48-10.5, PRN 3.80-95% CI 1.28-11.3). CONCLUSIONS: A label of dementia may bias the interpretation of pain cues of demented patients, while complaints from cognitively impaired patients may be taken for granted. This may contribute to lower use of PRN medication in demented patients compared to cognitively impaired patients.     

Custody and Caring: Clinical Placement of Student: Nurses in a Forensic Setting

topic . Clinical placement of student nurses in a forensic setting during their psychiatric nursing course.
source . Curriculum at the College of Nursing, University of Saskatchewan.
goal . To describe a unique setting for learning psychiatric nursing.
conclusion . Forensic settings provide an opportunity for student nurses, educators, and clinicians t work together to learn and to provide excellent care     

Solution Focused Therapy: An Alternative Approach to Addictions Nursing

topic : The application of solution-focused therapy as an alternative approach to addictions nursing.
purpose : To acquaint nurses with solution-focused therapy as a treatment modality that uses specific techniques to focus on clients'strengths and resources, rather than on pathology.
source : Traditional method of addictions treatment as a way of confronting a client's denial are contrasted with solution-focused therapy approaches, which provides a positive framework that uses clients'competencies to create necessary solutions.
conclusions : Solution-focused therapy represents a caring and humanistic approach to the practice of addictions nursing.     

Real-Time Automated Detection and Quantitative Analysis of Seizures and Short-Term Prediction of Clinical Onset

Summary: Purpose: We describe an algorithm for rapid realtime detection, quantitation, localization of seizures, and prediction of their clinical onset.
Methods: Advanced digital signal processing techniques used in time-frequency localization, image processing, and identification of time-varying stochastic systems were used to develop the algorithm, which operates in generic or adaptable "modes." The "generic mode" was tested on (a) 125 partial seizures (each contained in a 10-min segment) involving the mesial temporal regions and recorded using depth electrodes from 16 subjects, and (b) 205 ten-minute segments of randomly selected interictal (nonseizure) data. The performance of the algorithm was compared with expert visual analysis, the current "gold standard."
Results: The generic algorithm achieved perfect sensitivity and specificity (no false-positive and no false-negative detections) over the entire data set. Seizure intensity, a novel measure that seems clinically relevant, ranged between 35.7 and 6129. Detection was sufficiently rapid to allow prediction of clinical onset in 92% of seizures by a mean of 15.5 s.
Conclusions: This algorithm, which was implemented with a personal computer, represents a definitive step toward rapid and accurate detection and prediction of seizures. It may also enable development of intelligent devices for automated seizure warning and treatment and stimulate new study of the dynamics of seizures and of the epileptic brain.     

The Nurse-Client Alliance Model

topic . A nursing model for psychiatric nursing.
source . Author's clinical work, review of literature.
goal . To describe this model and its use with psychiatric clients.
conclusion . This model complements the biomedical model by helping clients gain insight and access to their subjective experience.     

Familial Unverricht-Lundborg Disease: A Clinical, Neurophysiologic, and Genetic Study

Summary: Purpose: Progressive myoclonus epilepsies (PMEs) are a clinically and etiologically heterogeneous group of disorders. The authors report clinical, neurophysi-ological, and genetic findings of a family from Southern Italy with three members affected with PME.
Methods: All data about familial and personal antecedents, clinical history, neurologic examination, laboratory tests, neurophysiological findings, brain imaging studies, and DNA analysis were examined.
Results: All results were compatible with the features of Unverricht-Lundborg disease and patients were homozygous for the "Finnish" ancestral haplotype.
Conclusions: Work is in progress to identify and characterize the common EPM1 mutation in the Finnish patients. Subsequently, it will be possible to verify the hypothesis on the existence of a common mutation in the Finnish patients and the Italian family under study, or even in other Mediterranean EPM1 families.     

Adult-Onset Rasmussen's Encephalitis: Anatomical-Electrographic-Clinical Features of 7 Italian Cases

Summary:  Purpose: A limited number of cases of adult-onset Rasmussen's encephalitis (A-RE) have been reported, but the features of the syndrome are still unclear. The aim of this study was to verify the clinical features of A-RE, and outline a noninvasive approach that may allow its early diagnosis and treatment.
Methods: Retrospective evaluation of extensive noninvasive work-up of seven patients with A-RE, including repeat clinical, neurophysiological, and neuroimaging investigations.
Results: The study identified two distinct patterns of disease presentation, one characterized by focal motor epilepsy (the "epileptic" phenotype), and the other by focal cortical myoclonus (the "myoclonic" phenotype). Unilateral neurological deficits and brain atrophy were progressive in both phenotypes, but they were more prominent and were detected earlier in the "epileptic" phenotype.
Conclusions: The anatomo-electroclinical features of these patients allowed a noninvasive diagnosis of A-RE and identification of two distinct disease phenotypes. Early noninvasive diagnosis can allow faster initiation of treatment.     

Using Margaret A. Newman's Theory of Health With Elderly Nursing Home Residents

TOPIC. The use of Margaret A. Newman's theory by psychiatric nursing students with elderly nursing home residents.
SOURCE. The author's work with baccalaureate nursing students.
CONCLUSIONS. Nurses who form relationships with elderly nursing home residents can help their clients identify problematic patterns, move to a choice point, then to a higher level of consciousness, resulting in a reduction in problematic patterns of behavior.     

Parkinson's disease and nursing home placement: the economic impact of the need for care

Background and Purpose:  To examine the relative risk (RR) for living in nursing homes for patients with Parkinson's disease (PD) compared with the general population and to ascertain society's costs related to nursing home placement for this patient group.
Methods:  We evaluated the frequency of admission to nursing homes in a cross-sectional study and during a 12-year follow-up study of 108 patients with PD and 864 controls who were matched for age and sex. The RR for living in a nursing home was calculated at baseline and during follow-up. On the basis of 2007 prices, we estimated the costs per person year of survival for patients with PD and controls.
Results:  The RR for living in a nursing home at baseline was 5.0 for patients with PD and 4.8 during follow-up. Patients with PD caused 4.8 times higher costs for nursing home placement with euro 18 875 versus euro 3978 per individual and year. The annual costs for institutional care of patients with PD in Norway were euro 132 million.
Conclusion:  Patients with PD have a substantially higher risk for living in nursing homes than the general population. This causes high costs to society. Therapeutic interventions to prevent or delay nursing home admissions are therefore important.     

Prospective analysis of risk factors for nursing home placement of dementia patients.

OBJECTIVE: To examine risk factors for nursing home placement in a community-based dementia cohort. METHODS: Cognitively normal participants and cognitively impaired patients from a large AD Patient Registry were followed from diagnosis to placement, death, or last follow-up. This included over 3,600 person-years of surveillance. The normal group included 473 participants who did not, at any point, meet Diagnostic and Statistical Manual of Mental Disorders, 3rd ed., revised (DSM-III-R) criteria for dementia. The patient group included 512 patients who met DSM-III-R criteria for dementia or criteria for mild cognitive impairment at diagnosis. Demographic, medical, social, cognitive, behavioral, and functional predictors of time to placement were examined using Cox modeling. RESULTS: In the normal group, only 21 people (4%) required nursing home placement. With subjects, enrollment year, age at initial evaluation, being widowed, and living in a retirement community were associated with time to placement in separate univariate analyses. Of 512 cognitively impaired patients, 203 (39.6%) were placed in nursing homes. Median time from diagnosis to placement was 5.3 years. Within the patient sample, four predictors were determined to be associated with time to nursing home placement. These included gender, enrollment year, functional status, and cognitive score. Interactions were present for functional status with cognitive score and enrollment year. CONCLUSION: In patients with dementia who are within 5 years of diagnosis, placement rates of approximately 10% per year can be expected. Disease severity indices including degree of cognitive and functional impairment are primary risk factors for placement.     

Dissociation in Epilepsy and Conversion Nonepileptic Seizures

Summary: Purpose: We examined the dimensionality of the item content of the Dissociative Experiences Scale (DES) in relation to the clinical diagnosis of conversion nonepileptic seizures (C-NES) versus complex partial epilepsy (CPE).
Methods : The DES was administered to a sex- and agematched sample of 132 patients with C-NES and 169 with CPE and was factor analyzed with principal components analysis (PCA) with varimax rotation.
Results : The mean total DES score was 15.1 in the C-NES group and 12.7 in the CPE group (p = 0.079). The factors obtained by PCA differentiated the CPE and C-NES groups more strongly than did the total DES score. The factor accounting for the most variance, interpreted as "depersonalizationderealization," was significantly greater in C-NES than CPE (p = 0.005). An "absorption-imaginative involvement" factor, which included some of the clinical features of posttraumatic stress disorder was elevated only in subjects reporting histories of childhood abuse (p = 0.001) regardless of the diagnosis of CPE or C-NES. An "amnestic" factor appearing to represent memory problems related to neurologic impairment showed a trend toward elevation in CPE (p = 0.056) and may have confounded the CPE versus C-NES distinction using total DES scores.
Conclusions : The DES has separate underlying dimensions that appear to relate distinctively to depersonalization and derealization, childhood trauma, and neurologic impairment. The heterogeneous item content of the DES is a potential confound that should be appreciated when this instrument is used to study dissociation in neuropsychiatric populations.     

The human perirhinal cortex in semantic memory: an in vivo and postmortem volumetric magnetic resonance imaging study in semantic dementia, Alzheimer's disease and matched controls

Introduction:  Studies in macaque monkeys indicate that the perirhinal cortex is critical for processes analogous to human semantic memory (i.e. memory for words, objects, faces and concepts). It is selectively impaired in semantic dementia (SD), the temporal lobe variant of fronto-temporal dementia, and less consistently in Alzheimer's disease (AD).
Materials and methods:  In vivo volumetric magnetic resonance imaging (MRI) data were collected from 30 cases (10 SD, 10 AD, 10 controls). Regions were outlined on successive scan slices and volumes calculated. Hippocampus, temporopolar, perirhinal and entorhinal cortices were measured bilaterally (using the protocol of Insausti et al . Am J Neuroradiol ; 19 : 23). High-resolution MR images from six cadaver brains have also been obtained. These will further clarify the relationship between cytoarchitectonic boundaries and gyral/sulcal landmarks.
Results:  Initial analyses indicate greater atrophy of the perirhinal cortex in SD than in AD ( P  < 0.00002). There is also a trend towards greater atrophy of posterior than of anterior entorhinal cortex in AD vs. SD.
Conclusions:  Cortical regions of the medial temporal lobe, defined by reference to cytoarchitecture, have been measured on MRI. As predicted by primate studies, but for the first time in man, perirhinal cortex atrophy is correlated with a neuropsychologically defined syndrome of semantic memory impairment.     

Acceptability and effectiveness of a strategy for the communication of the diagnosis of psychogenic nonepileptic seizures

Purpose:   Communicating the diagnosis of psychogenic nonepileptic seizures (PNES) is a challenging task. This study was carried out to assess the acceptability and effectiveness of a new communication procedure consisting of a patient information leaflet and a communication strategy for neurologists.
Methods:   In a multicenter prospective study, 50 patients newly diagnosed with PNES were informed about the diagnosis by 10 different neurologists using the communication procedure. Follow-up data were gathered by telephone interview and completion of a questionnaire about symptom attributions (psychological/physical) and illness cognitions (Illness Perception Questionnaire-Revised, IPQ-R).
Results:   Ninety-four percent of patients found the leaflet easy to understand. Ninety-four percent stated their questions were answered by the doctor; 70% got what they wanted from the consultation; only 4% reported feeling angry during the consultation. Eighty-six percent of patients acknowledged that psychological factors were at least contributing to their seizures. On the IPQ-R, "emotional" causes for the seizures were endorsed more commonly than "nonemotional" causes (p < 0.001). After 3 months, 14% of patients were seizure-free and 63% reported a >50% reduction in seizure frequency.
Discussion:   We conclude that our procedure is acceptable and effectively communicates a psychological etiologic model for PNES.