Chapter 9: Working With the Individual Psychiatric Patient

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Welcome back to the Deep Dive.

Today we are shifting gears a little bit.

We're stepping away from the purely physiological side of healthcare, you know, the IVs, the wound dressings, the pharmacology charts, and we are walking into a room where the primary tool isn't a stethoscope.

It's not a scalpel.

It's not even a pill, really.

It's you, the nurse.

It's you.

That's right.

That's exactly it.

Today we are tackling chapter nine of Psychiatric Nursing, the seventh edition.

And the title of this chapter is, it sounds so simple, Working with an Individual Patient.

Which sounds completely straightforward, right?

You walk in, you help the patient, you walk out.

But, you know, as I was reading through this chapter, I just realized that psychiatric nursing is, it's fundamentally different from any other kind of nursing.

It seems like in other fields, you do things to the patient.

You fix the bone, you give the meds, you change the dressing.

But here, the text keeps coming back to this phrase, the therapeutic use of self.

It is a profound shift.

And honestly, for nursing students, especially when they're often the most terrifying part.

I can imagine.

They know how to give a shot.

They can memorize the steps for a catheter insertion.

But they don't necessarily know how to just sit in silence with someone who is, you know, experiencing a completely different reality.

There's no checklist for human connection like there is for a sterile procedure.

Exactly.

So our mission today is really to guide you through this whole idea of the nurse -patient relationship.

We want to break down what it actually means to be therapeutic without

falling into that trap of trying to be a therapist.

Oh, that's a big one.

Because there is a difference and it's a huge one.

A massive difference.

Yeah.

And we are going to cover the whole roadmap the text gives us.

Yeah.

We'll look at the nature of this relationship, the specific stages it goes through, because it really does have a beginning, a middle, and an end.

And then we're going to get very tactical.

We'll look at how you handle specific, really difficult behaviors, things like hallucinations,

anger,

manipulation.

We aren't just going to talk about them extractively.

We're going to get into what you actually say.

And we'll wrap all of that up by applying the famous nursing process, specifically to psychiatry.

And we'll end with a really deep look at a case study from the text, a woman named Mrs.

Anita Jarvis.

Sounds good.

But before we dive into all the heavy theory, I really love this little sidebar in the text.

It was called Norm's notes.

Yes.

Norm's notes are great.

They always ground the theory in like everyday reality.

Totally.

And Norm points out that learning to be therapeutic is actually a life skill.

It's not just for the hospital.

He asks, how do you react to an angry person?

Or when a friend learns her husband is leaving her.

And that's the hook right there.

The skills we are discussing today, active listening, maintaining your boundaries, empathy.

These are universal.

If you learn them for your nursing career, I promise you, you will find yourself handling your friend's breakup,

or a tense family dinner, or a crisis with a partner with a completely different level of competence.

It changes everything.

It really does.

It changes how you relate to people everywhere.

So, okay, let's start with the foundation.

The text cites Hildegard Peplau, who is basically the heavy hitter in this field.

She defined nursing way back in 1952.

She did.

Peplau is to psychiatric nursing, what, I don't know, Florence Nightingale is to general nursing.

She completely revolutionized the field.

She defined nursing as a significant therapeutic interpersonal process.

A mouthful.

It is.

But she also called it an educative instrument and a maturing force.

That sounds very poetic, a maturing force.

But what does that actually mean, you know, practically on the floor?

It means that the interaction itself is the treatment.

Peplau believed that the nurse and patient,

they start as strangers, and they move through these stages to become collaborators.

And that word collaborator is so key.

The text emphasizes collaboration over compliance.

I highlighted that because in a traditional medical model, we love compliance, you know, take this pill, stay in bed, doctor's orders.

We kind of view the patient as this passive recipient of care.

But here, the text is saying collaboration produces more Well, think about it.

If I force you to change your behavior because I'm the authority figure, you might do it while I'm watching you.

Sure.

You might act compliant just to get discharged.

But if we collaborate, if we identify the problem together and you decide you want to change,

that's what sticks.

Patients have a right to make decisions about their care.

If they don't buy into the plan, that plan is going to fail the moment they walk out the door.

But there is a caveat here, the text mentions situations where collaboration isn't really on the table.

Correct.

We have to be realistic.

If a patient has severe disturbances in their thought processes, we're talking about active hallucinations, delusions, or they're a clear danger to themselves or others.

You can't exactly collaborate on safety in the same way.

You don't ask a patient who's holding a chair above their head.

So how would you like to proceed with this?

Right.

Do you feel like putting the chair down?

That's probably not the move.

No.

In those really acute moments, the goal shifts.

It's all about safety and stabilization.

The nurse has to take control to provide the structure that the patient has lost.

But, and this is important, the moment they are lucid, the moment that crisis passes, you move right back to collaboration.

Okay.

So we're collaborators, but we are not friends.

And this seems to be like the biggest trap for students.

The text talks a lot about social versus therapeutic relationships.

It is the most common pitfall.

Absolutely.

Yeah.

You have a patient who might be lonely.

Maybe they're roughly your age.

Maybe they remind you of your cousin or something.

They start asking personal questions.

They want to be your friend.

They want to be your friend.

Or, as the text notes, they might even ask you on a date.

Which would be flattering in a coffee shop, but on a psych ward, that's a problem.

It's a boundary violation.

See, a social relationship is mutual.

It's about both of getting our needs met.

We share stories.

We vent to each other.

Maybe we lend each other money.

A therapeutic relationship is entirely different.

How so?

It's objective and goal -directed.

It is 100 % about the patient.

The nurse's needs, your need to be liked, to vent, to feel important.

All of that has to be checked at the door.

So if a patient asks for a date, or even just says something like, hey, let's hang out after you get off shift, how does the text suggest we handle that without being mean?

Because rejection can trigger a lot of these patients.

You have to be firm but validating.

The text gives a great script for this.

You acknowledge the human need that's behind the request.

You'd say something like, I realize you would like to date.

Or, I realize you need friendship.

But then you set the boundary very clearly.

As a nurse, my role is to help you find ways to form friendships that can offer you emotional support outside of here.

So you're validating the need, the loneliness, but you're rejecting the method dating the nurse.

Exactly.

And you are modeling a healthy boundary.

Many of our patients have never experienced a relationship where someone cares for them but doesn't want something from them, you know, sexually or socially.

By holding that line, you're actually teaching them something incredibly profound.

Now let's distinguish between being therapeutic and providing therapy.

This feels important because I think students feel this pressure to be like a mini -froid.

And they absolutely shouldn't.

The text makes a very clear distinction.

Providing therapy, so like formal 50 -minute sessions where you're digging into deep -seated trauma using a specific modality like CBT or psychoanalysis.

That is for advanced practice nurses, APRNs, psychologists, social workers.

So what is the BSN nurse or the student nurse doing then?

The bedside nurse is being therapeutic.

And this happens in the milieu, that's just the word for the environment.

It happens during a card game or while you're passing meds or in just a brief hallway conversation.

The text mentions informal encounters, things like card games or craft classes.

Yes.

Okay.

Let's say you're playing cards with a patient.

You aren't analyzing their childhood.

But if they lose a hand and they flip the table, you now have a therapeutic opportunity.

You can say, I see you're frustrated.

Let's talk about how to handle losing a hand without getting aggressive.

You are using that moment to build social skills and reality tests.

That's being therapeutic.

It's like real -time coaching.

I love that distinction.

It really takes the pressure off.

You don't have to cure their schizophrenia.

You just have to help them handle the card game.

Exactly.

One last thing on the nature of this relationship,

self -disclosure.

The text has a rule of thumb for when nurses can or should share personal information.

And the rule is simple.

It must benefit the patient.

You should very, very rarely disclose personal details.

If you do, it's to build rapport or to normalize a feeling.

Can you give an example?

Sure.

You might say, I know what it's like to feel angry when things don't go my way.

That's okay.

But you never, ever burden the patient with your own problems.

If you find yourself talking about your divorce because you need a vent or talking about your financial struggles, you have crossed the line.

You're using them.

You're using the patient to meet your needs, which flips the relationship right back to social or even exploitative.

Got it.

So that's the nature of the relationship.

Now let's look at the structure.

Peplau breaks this all down into three stages.

Right.

The orientation stage, the working stage, and the termination stage.

Let's start with orientation.

This is the, hello, I'm your nurse phase.

Exactly.

Peplau calls this the stranger phase.

The patient and nurse, you don't know each other.

The goal here is pretty straightforward.

Building trust and assessing their needs.

You're also establishing the contract.

Now, when you say contract, we don't mean like a legal document they sign with a lawyer or anything.

No, no.

It's a verbal agreement.

You set the time, the length of your meetings, and the purpose.

My name is nurse Sarah.

I'll be your nurse until 7 p .m.

We're going to meet for 15 minutes at 10 a .m.

to discuss your anxiety.

That's struster.

It reduces anxiety because the patient knows exactly what to expect.

The text also mentions the confidentiality limits.

Specifically, I could pay I.

We have to tell them that what they say is private, but there's an exception.

Except if it involves harm to self or others.

This is non -negotiable.

You have to be honest about that right up front.

You can't promise, oh, I won't tell anyone.

Because if they tell you they hit a razor blade under their pillow or they plan to hurt their neighbor when they get out.

You have to tell someone.

You absolutely have to tell someone.

If you promise secrecy, you've now broken their trust.

So you say everything is confidential within the treatment team unless it involves safety.

Managing emotions is huge in this first stage.

Patients are coming in feeling fear, guilt, anger.

And the text warns against a really common habit.

False reassurance.

Oh, this is a big one.

It is so tempting to say don't worry.

Everything is going to be all right.

We say it to make ourselves feel better.

Right.

We see pain and we want to just bandage it with words.

But in psychiatry, it's dishonest.

We don't know if it will be all right.

Maybe their spouse really is leaving them.

Maybe they're going to lose their job.

So what do we do instead of that?

We use empathy.

And we really need to distinguish empathy from sympathy.

Sympathy is feeling with the patient.

Oh, you poor thing.

I feel so sad for you.

You get down in the hole with them.

You get stuck.

You get stuck.

You lose your objectivity.

You can't help pull them out if you're in the mud too.

Empathy is objective understanding.

I hear how painful this is for you.

You remain separate enough to be helpful.

You're standing on the edge of the hole dropping down a ladder.

The orientation phase is also where we provide structure.

What does that look like?

It means taking temporary control if the patient loses it.

If a patient is escalating, yelling or pacing aggressively, you provide safety.

You might use a quiet room or you might simply set limits.

I can see you are angry, but I cannot let you yell at the staff.

So you're setting a boundary.

You're providing structure.

It tells the patient, I will keep you and everyone else safe, even if you can't control yourself right now.

Okay, so we've met them.

We've set the boundaries.

We built some trust.

Now we move to stage two, the working stage.

This is the core of it.

This is where the actual work happens.

The goal here is changing thoughts, feelings and behaviors.

And the text lists some specific tools we can use.

One is reality testing.

This is so crucial for patients with psychosis.

If a patient hears voices or sees things that aren't there, you don't argue with them, but you also don't play along.

You offer constructive feedback.

Like what?

You say, I know the voices seem very real to you, but I don't hear any.

You are defining reality for them.

You become their anchor to the real world.

Another tool is cognitive restructuring.

That sounds kind of like rewiring the brain.

In a way, it is.

It's helping a patient swap these irrational beliefs for rational ones.

For example, a patient might think, I must be perfect or I am a total failure.

That's a very common one.

So irrational and so depressing.

You help them restructure that to something like, it's okay to make mistakes.

I can learn from them.

You challenge the logic or the lack of logic in their negative self -talk.

The text also emphasizes motivational interviewing here.

This seems to be the gold standard for helping people change, especially with addictions.

It is.

And the key concept in motivational interviewing is ambivalence.

It is completely normal to want to change and not want to change at the exact same time.

Like wanting to lose weight, but also really wanting to eat a whole pizza.

Exactly.

And in psych, it might be, I want to stop drinking, but alcohol is the only way I know how to cope.

Motivational interviewing says, don't fight that resistance.

Roll with it.

What does that mean?

Roll with it.

If you push them,

you have to stop.

They will push back.

You can't make me.

Instead, you express empathy, but you help them see the discrepancy between their behavior and their goals.

You might say, you said you want to get your kids back.

How does the drinking help with that?

You let them argue for the change.

This connects to the stages of change model by Prochaska and Norcross.

The text breaks this down into five stages.

I think this is so helpful for understanding why patients don't just snap out of it.

Yes.

Let's run through them quickly because identifying where your patient is determines your entire strategy.

Okay.

First, you have pre -contemplation.

This is the, I don't have a problem stage.

The patient isn't even thinking about changing.

They're in denial.

I'm fine.

I'm fine.

Everyone else is the problem.

Second, contemplation.

Maybe I have a problem.

They're ambivalent.

They're thinking about it, but they're not committed.

Weighing the pros and cons.

Third is preparation.

Now they're getting ready.

Maybe they're looking up rehab centers or planning a new schedule.

They're on the verge of acting.

Fourth is action.

They're actually doing it.

Modifying behaviors, going to the meetings,

throwing away the bottles.

And the last one.

Fifth is maintenance, preventing relapse.

The change has happened and now the work is sustaining it.

So as a nurse, if you try to force action strategies on someone who is in pre -contemplation, you're just going to fail.

You're going to fail and you're going to create more resistance.

If someone is in pre -contemplation, your goal isn't to get them to quit today.

It's just to raise awareness, to plant a tiny seed, if to meet them where they are.

Eventually, though, the shift ends where the patient is discharged.

That brings us to stage three, termination.

The end.

This happens at discharge or even just when your clinical rotation ends.

And the danger here is regression.

Patients might feel abandoned.

They might act out.

They might start acting out again to keep you there.

It's so common for a patient to suddenly say they're suicidal again right before discharge because they are terrified of leaving the safety of that relationship.

So how do we handle it?

You prepare for it in advance.

You don't just spring it on them on the last day.

You summarize their progress.

Look how far you've come.

You reinforce their strengths.

You discuss the future referral support groups and you say a formal goodbye.

You give it closure.

You give it healthy closure.

It establishes that this was a professional relationship that has concluded successfully.

It models that a relationship can end without destruction or abandonment.

Okay, let's get into the how to section.

Section three of our roadmap covers interactions with selected behaviors.

This is the part of the chapter that feels like a survival guide.

I want to kind of rapid fire some of these because the text gives very specific advice on what to do when things get tricky.

Let's do it.

First up, violent behavior.

This is the one everyone fears.

Safety first, always.

Stay at a striking distance that's usually an arm's length plus a step.

Don't touch the patient without approval.

Touch can be seen as a threat or an attack.

Don't go in alone.

Never enter a room alone if they're agitated and call for help.

Sometimes a show of force, just having several staff members present is enough to deescalate without anyone touching anyone.

Okay, hallucinations.

The text gives a five -step sequence for this.

This seems super important for students to memorize.

It is.

Step one, comment on the behavior.

You look like you're listening to something.

You're just observing.

And not judging.

Not judging.

Step two, ask what they hear.

Tell me what you hear.

You have to know if the voices are command hallucinations, telling them to do something dangerous like jump out the window.

Right.

Step three, assess the content, the themes of guilt, power,

fear.

Step four, de -emphasize.

This is the pivot.

You say, I know the voices are important to you, but let's talk about your loneliness.

You validate the feeling, but you move away from the hallucination.

And step five, distract.

Engage them in reality -based activities.

Why de -emphasize?

Why not just talk about the voices if that's what's real to them?

Because discussing the voices at length validates them as reality.

If we spend 30 minutes talking about the man on the wall, I am reinforcing that the man on the wall is real and worth our time.

You want to focus on the patient, not the hallucination.

The exception, as the text notes, is dementia patients.

For them, you just ignore and distract immediately because they can't process that kind of insight.

Okay.

Next, delusions.

Like the FBI is chasing me or I am the Queen of England.

You clarify the meaning first, who is trying to hurt you.

But then you stop discussing the delusion.

And the big rule is, do not argue.

You can't logic your way out of a delusion.

You will never win an argument against a delusion.

It just strengthens their belief.

If you say, you can't be the Queen, they'll just think that's exactly what a traitor would say.

So if they say, I am the Queen, what do I say?

You look for the underlying feeling.

Being the Queen means feeling important or powerful.

So you treat them with respect and you help them find ways to feel important in reality.

You aren't the Queen, but you are a respected patient here and I'd love for you to light the card game.

You address the need for self -esteem without buying into the fantasy.

Conflicting values.

What if a patient says, drinking is legal, so I can drink all I want.

And that just grates against your value of health.

If the belief doesn't cause harm to others, you generally leave it alone.

But if it does, like drinking themselves to death, you use what the text calls supportive confrontation.

You don't attack the value, you examine the effect.

How does that sound?

You say you have the right to drink and that's true.

But let's just look at what drinking has cost you.

Your job, your marriage, your health.

You let the consequences make the argument for you.

Okay,

severe anxiety or incoherent speech.

When they're just frantic and you can't understand them.

Keep it simple.

Don't keep asking what do you mean over and over again.

That just makes them more anxious because they can't explain it.

You want to key into the feelings or themes.

It sounds like you're very scared.

And spend frequent brief intervals with them so they don't feel abandoned.

But don't force a long conversation.

Just be a calming presence.

Manipulation.

This is the patient who pits staff against each other.

You're the only good nurse here.

The night nurse is terrible.

Classic splitting.

And it feels good to be the good nurse, but it's a trap.

You have to address the behavior directly.

I see you asking for a lot of attention.

Do not get into a power struggle.

Set limits and communicate with the rest of the staff so you are all on the same page.

Insistency is key.

Consistency is the cure for manipulation.

If you say no to the extra snack and the next nurse says yes, the manipulation works.

Crying.

Allow it.

Offer tissue.

Provide some privacy.

It's a tension reliever.

Don't rush to stop the tears.

Just sitting there in silence while someone cries is an incredibly powerful intervention.

Sexual innuendos or touch.

Firm limits.

Immediately.

I want to talk to you, but not if you touch me.

Or that comment is inappropriate.

If it continues, you leave and say you'll come back later.

You have to maintain that boundary because they often cannot.

Denial and lack of cooperation.

The classic.

I don't have a problem.

I don't need to be here.

This is often rooted in fear.

It's safer to deny the problem than it is to face it.

So you discuss the fear.

What are you afraid will happen if you give up alcohol?

What scares you about taking this medication?

Depressed or apathetic.

The patient who just will knock it out of bed.

Patients.

Frequent contact.

Empathy.

Don't try to force major decisions.

Encourage basic hygiene and nutrition.

Sometimes just getting them to take a shower is the therapy for the day.

You're basically lending them your energy until they have some of their own.

Suspiciousness.

Paranoia.

Be clear, simple, and consistent.

Explain all the rules and all the noises.

If there's a loud bang in the hall, you tell them what it was immediately.

That was just a cart falling over.

Don't whisper in front of them.

They will think you're plotting against them.

And don't force participation in groups if they're terrified.

Hyperactivity.

The manic patient.

They need a quiet area with low stimuli.

Dim the lights.

Speak slowly and softly to counterbalance their energy.

If you get hyper with them, they will only escalate.

You have to be the calm anchor in their storm.

And finally, a big concept duo.

Transference and countertransference.

These are Freudian terms, but they are so real in nursing.

Break it down for us.

Okay,

so transference is when the patient projects old feelings onto you.

They might say, you act just like my mother and then get angry at you.

Not because of what you did, but because of their unresolved issues with their mom.

And countertransference.

Is the reverse.

It's when the nurse reacts to the patient based on the nurse's own past.

Maybe a patient reminds you of a bully from high school, so you find yourself being short with them.

Or maybe they remind you of your sweet grandmother, so you're overly protective.

And the tech says we have to monitor this in ourselves.

Constantly.

You have to be self -aware.

If you feel irrationally angry or overly affectionate toward a patient, you have to ask yourself, is this countertransference?

Am I reacting to them or am I reacting to a ghost from my past?

Okay, moving on to section four.

The nursing process in psychiatry.

We all know the nursing process assessment, diagnosis, planning, implementation, evaluation.

It's the backbone of all nursing.

But how does it look different here?

Well, it starts with the assessment.

In the intake, we're gathering the usual demographics, but we're also specifically looking for emergency behaviors.

Suicide risk.

Aggression.

And the text really emphasizes checking for medical problems.

Box nine to one in the chapter highlights this.

It notes that psych patients die 30 % sumer due to under -treated medical issues.

That is a staggering statistic.

It's awful.

Just because they're admitted for depression doesn't mean they don't also have diabetes or hypertension or an infection.

Sometimes the psychosis is actually a UTI in an elderly patient or a thyroid storm.

We have to assess the whole.

Then we have the mental status examination or MSE.

This is basically the psychiatric equivalent of a physical exam.

Exactly.

It's a snapshot of the patient's current state.

It's not their history.

It's how they are right now.

And there are specific categories you have to check.

Let's go through them.

Okay.

General appearance.

Are they grooming?

Are they slouched?

Are they dressed appropriately for the weather?

Behaviors.

Cooperative.

Resistant.

Pacing.

Motor activity.

Are they agitated?

Or retarded?

Which in this context means psychomotor retardation moving very, very slowly like they're moving through molasses.

Speech.

What are we listening for?

Is it pressured?

You know, fast and hard and interrupt.

Is it soft or they mute?

And then there's affect versus mood.

I feel like students always mix these two up.

They do.

It's a classic.

The easy way to remember it is mood is what they say they feel.

If you ask, how's your mood?

Yeah.

They'll say, I'm depressed.

Affect is what you see on their face.

It might be flat or smiling or crying.

And sometimes they don't match.

Right.

And that's an incongruent affect, which is important data.

Then you have thought content.

What are they thinking about?

Suicide, delusions, obsessions, and thought process.

How are they thinking?

Is it word salad?

Just jumbled words?

Is it flight of ideas jumping topic to topic?

And lastly.

Insight and judgment.

Do they know they're ill?

Do they understand they need help?

And can they solve problems?

If the fire alarm went off, would they know to leave the building?

OK.

Then comes the nursing diagnosis.

We use Nanda diagnoses for this.

And the formula is always problem plus related to the etiology plus as evidenced by the symptoms.

For example, anxiety related to marital problems as evidenced by ineffective problem solving and pacing.

This structure helps us organize our care.

And outcomes.

They have to be realistic.

Realistic and measurable.

You are not going to cure depression in three days.

A good goal might be patient will sign a no harm contract or patient will express anger verbally rather than physically.

Small achievable steps.

Finally, progress notes.

The text suggests the SOAP format.

Yep.

Subjective what they say.

Objective what you see.

Analysis.

Your impression of the themes.

And plan what you're going to do next.

And always remember the chart is a legal document.

If you didn't document it, it didn't happen.

All right.

Let's bring all of this to life.

The text provides a really comprehensive case study of Mrs.

Anita Jarvis.

I think walking through her case will help clarify how all these pieces fit together.

Mrs.

Jarvis is a classic presentation.

She's a 46 -year -old female.

She was evicted for depression.

And the situation.

Her husband asked for a divorce and left her one week ago.

Her symptoms.

She hasn't been eating or showering.

She's just staying in bed.

And she told her children she wishes she were dead.

So applying the MSE, the mental status exam, to Mrs.

Jarvis, as it's shown in Box 9 -2 in the book, what do we see?

OK, so her appearance.

She has unwashed hair, slouched shoulders.

She just looks defeated.

Her speech,

it's slow and soft.

What about her thoughts?

Her thought content.

She expresses a lot of helplessness.

Importantly, she denies any hallucinations.

She's in touch with reality.

She's just completely crushed by it.

She says she wishes she were dead, which is passive suicidal ideation.

But she has no specific plan.

And her judgment.

Her judgment is impaired recently.

She hasn't been able to make basic decisions or take care of her needs.

The text provides a process recording of an interaction with her in Table 9 -1.

This is a verbatim written record that's used for learning.

Let's look at the technique the nurse is using here.

So the nurse introduces himself.

Mrs.

Jarvis is just looking at the floor.

The nurse asks a great open -ended question.

What has happened in your life recently?

And her response is, I don't know, a week, I guess.

She's confused, slow.

Right.

That's that psychomotor retardation we talked about.

Her brain is literally processing information slowly because of the depression.

Now, looking at that table in the text, there's a moment where the nurse just observes her nonverbal behavior.

She's looking at the floor, turning her head.

And the nurse uses silence and active listening.

He doesn't rush in to fill that void.

I noticed in the outline there was a mention of the phrase, you look as if you are listening to something.

But looking closely at Table 9 -1 in the source, the nurse actually leans forward and says, I can see this is difficult for you to talk about.

Correct.

He's using focusing and using empathy.

He is acknowledging her pain.

He's validating that it's hard for her to speak.

And then later, he asks the hard question.

This is a sad question.

Yeah.

He asks, when you were feeling so tired, did you have thoughts of killing yourself?

That is such a scary question for a student to ask.

They always worry it'll put the idea in her head.

It won't.

That is a total myth.

You have to ask directly.

And her answer is so telling.

She says, I thought I'd rather be dead.

Passive ideation.

Right.

She wants to be gone.

But she isn't saying, I'm going to crash my car.

So the nurse then assesses for a plan.

How did you think about killing yourself?

And she says, I couldn't think of anything.

I didn't know what to do.

So no plan.

Which puts her at a lower immediate risk than someone with a gun and a date.

But she's still high risk because of the sheer hopelessness.

So what does the care plan for Mrs.

Jarvis look like?

OK.

So the diagnosis is risk for suicide related to impending divorce and hopelessness related to lowered self -esteem.

And the goals?

Short term.

Patient will agree to talk to staff when she feels suicidal.

That's a safety contract.

Long term, patient will express anger.

Why express anger?

She seems so sad, not angry.

In psychiatry, we often say that depression is anger turned inward.

She's angry at her husband for sure.

But she's taking it out on herself.

She feels guilty, not furious.

Helping her externalize that anger, getting her mad at him instead of hating herself can be a huge part of lifting the depression.

And the interventions?

Suicide precautions.

Fluoxetine, 20 milligram, which is an antidepressant.

And group therapy, specifically a grief and loss group.

And looking at her progress note in Box 9 -3, we can see that SOAP format in action.

We can.

Subjective.

She says, I still wish I were dead.

Oh, objective.

Blunted effect.

Napped two hours.

A.

Analysis.

Gulch and helplessness are evident.

P.

Plan.

Monitor suicidal ideation.

Continue meds.

It's a clean, clear record of where she is and where we're going.

And it shows that even with intervention, progress is slow.

She didn't just snap out of it in one conversation.

But she's safe.

And she's in treatment.

It really shows that psychiatric nursing isn't just chatting.

It is a structured, scientific approach to human connection.

Absolutely.

The nurse -patient relationship is the scalpel of psychiatric nursing.

It's the tool we use to excise the infection of hopelessness and suture the wounds of trauma.

It requires just as much skill and precision as any surgical procedure.

That is a powerful image.

So to recap, we've covered Pepe Law's definition of nursing.

We've walked through the stages orientation, working, termination.

We've armed you with scripts for things like hallucinations, delusions, manipulation.

And we've seen it all applied to Mrs.

Jarvis.

We have covered a lot of ground today.

As we wrap up, I want to leave our listeners, especially the nursing students out there, with a final thought.

We talked about Norm's notes at the very beginning about how this is a life skill.

So think about your own interactions this week.

When a friend calls you complaining about their partner or a family member snaps at you, what is your default setting?

Do you rush in to fix it with that false reassurance, oh, don't worry, he didn't mean it?

Or do you get defensive?

Or can you sit in the discomfort?

Or can you use that therapeutic self to just say, I hear how angry you are.

Tell me more about that.

That ability to witness someone's pain without trying to immediately bandage it over, that is the difference between being a nice friend and being a therapeutic presence.

And that is the superpower of the psychiatric nurse.

Thank you so much for joining us on this deep dive.

Thank you.

This has been the Last Minute Lecture Team signing off.

Good luck on your rotation.