Learn Mental health nursing from scratch
Before this: Nursing fundamentals
1The therapeutic relationship
In mental health nursing, the relationship itself is a treatment. Peplau describes three phases: orientation (trust and boundaries), working (exploring problems and practising new behaviour) and termination (reviewing progress and ending).
Therapeutic techniques help the patient talk:
- Open questions: “How have you been feeling?”
- Reflection: “You feel that no one cares about you.”
- Clarifying, summarising, focusing and using silence.
- Presenting reality: “I don’t hear the voices, but I can see they upset you.”
Non-therapeutic responses block communication: false reassurance (“Don’t worry”), giving advice, approving or disapproving, changing the subject, and “why” questions that make the patient defensive.
Transference is the patient reacting to the nurse as to someone from their past; countertransference is the nurse’s own emotional reaction, which belongs in supervision.
Self-check A patient says, “I’m a failure at everything.” Which response is therapeutic?
- “Don’t say that; you are doing great.”
- “Let’s talk about the weather instead.”
- “Why do you think that?”
- “You feel you have failed. Tell me more about that.”
Answer: “You feel you have failed. Tell me more about that.”. Reflecting the feeling and inviting more keeps the patient talking. Contradicting gives false reassurance, a “why” question can feel like an accusation, and changing the subject shows that you do not want to hear it.
2Defence mechanisms and the mental status exam
Defence mechanisms protect against anxiety, usually without awareness:
- Denial: refusing to accept reality. Projection: putting one’s own feelings onto others.
- Displacement: redirecting feelings to a safer target. Rationalisation: a logical-sounding excuse.
- Regression: returning to an earlier stage. Reaction formation: showing the opposite feeling.
- Repression is unconscious; suppression is conscious. Sublimation is a mature defence.
The mental status examination describes the patient now:
- Appearance, behaviour and speech.
- Mood (what the patient says) and affect (what you observe: flat, blunted, labile, incongruent).
- Thought process: flight of ideas, tangentiality, circumstantiality, loose associations, clang associations, neologisms.
- Thought content: delusions, obsessions, suicidal or homicidal thoughts.
- Perception (hallucinations, illusions), cognition, insight and judgement.
3Major disorders at a glance
- Schizophrenia: positive symptoms (hallucinations, delusions, disorganisation) and negative symptoms (avolition, alogia, anhedonia, flat affect). Do not argue with delusions; respond to the feeling and keep to reality.
- Depression: low mood, loss of interest, hopelessness. Assess suicide risk at every contact.
- Bipolar mania: little need for sleep, grandiosity, pressured speech. Offer a low-stimulus setting, firm limits and finger foods.
- Anxiety and panic: stay with the patient, use short sentences and a calm space. Rule out physical causes of chest pain.
- OCD: do not stop rituals abruptly. PTSD: grounding during flashbacks.
- Borderline personality disorder: splitting and self-harm; use consistent team limits.
- Eating disorders: watch potassium in bulimia and refeeding syndrome in anorexia.
- Alcohol withdrawal: tremor after 6–24 hours, seizures 12–48 hours, delirium tremens about 48–96 hours. Benzodiazepines and thiamine.
- Delirium: acute and fluctuating, with a physical cause. Dementia: gradual.
4Psychotropic drugs: what nurses watch
- SSRIs: full effect after several weeks; watch for suicidal thinking early in treatment, especially in young people.
- MAOIs: avoid tyramine-rich foods. A severe occipital headache may be a hypertensive crisis. Allow a washout of about 2 weeks before an SSRI.
- Tricyclics: anticholinergic effects; overdose causes arrhythmias and seizures.
- Lithium: narrow range, often quoted as about 0.6–1.2 mmol/L (targets vary). Dehydration, low salt, NSAIDs, thiazides and ACE inhibitors raise the level. Sample about 12 hours after the dose; monitor kidney and thyroid function.
- Valproate: liver, pancreas, pregnancy. Carbamazepine: blood counts and skin. Lamotrigine: report any rash.
- First-generation antipsychotics: acute dystonia, akathisia, parkinsonism, tardive dyskinesia.
- Second-generation antipsychotics: weight, glucose and lipids.
- Clozapine: regular neutrophil counts; report fever or sore throat at once; watch for constipation, myocarditis and seizures. Stopping smoking can raise its level.
- Benzodiazepines: sedation and dependence; taper, never stop abruptly after long use.
Two emergencies are often confused. Neuroleptic malignant syndrome develops over days after a dopamine blocker, with fever, “lead-pipe” rigidity, confusion and a raised CK.
Serotonin syndrome starts within hours of a serotonergic change, with agitation, sweating, hyperreflexia and clonus. In both, stop the drug and get urgent medical help.
Self-check A patient on lithium has had diarrhoea for two days and now has a coarse tremor. What is the likely problem?
- A normal fine tremor at therapeutic levels
- Lithium toxicity caused by fluid and sodium loss
- Serotonin syndrome
- Tardive dyskinesia
Answer: Lithium toxicity caused by fluid and sodium loss. Fluid and sodium loss make the kidneys keep lithium, so the level rises. A fine tremor is a normal side effect, but a coarse tremor with GI symptoms suggests toxicity. Hold the dose and get an urgent level.
5Safety, risk and the law
Suicide risk: ask directly; asking does not increase risk. Explore thoughts, plan, intent, means, timing, previous attempts and protective factors. A previous attempt is a strong risk factor.
Warning signs include giving away possessions, saying goodbye, sudden calm after deep depression and statements about being a burden. No-suicide contracts are not reliable; use safety plans, reduce access to means and observe closely when risk is high.
Aggression: notice early signs (pacing, clenched fists, raised voice) and de-escalate calmly, keeping a safe distance and an exit. Restraint and seclusion are last resorts, with continuous monitoring of breathing and circulation.
General legal and ethical principles (laws differ between countries): the least restrictive alternative, informed consent and the right to withdraw it, assessment of capacity, the rights of involuntary patients, and confidentiality with exceptions when there is a serious risk to the patient or an identifiable person.
6A worked example
Decide your next step before opening each one.
Worked exampleFive days after starting haloperidol, Mr de Vries has a temperature of 40.1 °C, rigid arms, a blood pressure that swings between 90/60 and 170/100 mmHg, heavy sweating and new confusion. What do you do?
1Fever, rigidity, autonomic instability and confusion days after starting an antipsychotic suggest neuroleptic malignant syndrome. The slow onset and the lack of clonus or hyperreflexia point away from serotonin syndrome.
2Withhold the antipsychotic and any other dopamine-blocking drugs, and do not give further PRN doses.
3Call for urgent medical review using SBAR. Transfer to a medical or intensive care setting may be needed.
4Monitor airway, breathing, circulation and temperature closely. Start cooling and IV fluids as ordered, and expect blood tests such as CK and kidney function.
5Record the findings and the drug history, reassess often and make sure the reaction is recorded for the future.
Answer Treat it as possible neuroleptic malignant syndrome: stop the antipsychotic, get urgent medical help, give supportive care and monitor closely.
7How exam questions look
- Easy (key terms and facts): defence mechanisms, mood versus affect, symptoms of a disorder, drug classes.
- Medium (applying the concepts): choosing the therapeutic response, MSE terms, lithium teaching, side effects and monitoring.
- Hard (cases and analysis): which patient first, which finding needs immediate follow-up, recognising toxicity or a drug emergency, and acting on suicide or violence risk within ethical limits.
In hard questions, safety comes first: physical emergencies and immediate risk of harm before communication goals.
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