Welcome toWelcome toPsychiatric MentalPsychiatric Mental

Health Health NursingNursing

Psychiatric Nurses care and communicatePsychiatric Nurses care and communicate

All good nurses are psych nurses whether All good nurses are psych nurses whether they want to admit it or not!they want to admit it or not!

Mental Health DefinitionMental Health Definition

Absence of mental illnessAbsence of mental illness

Adaptation to stress with culturally age Adaptation to stress with culturally age appropriate thoughts, feelings and appropriate thoughts, feelings and behaviorsbehaviors

Successful ability to perform in mental Successful ability to perform in mental functions which result in productive functions which result in productive activities, fulfilling relationships and activities, fulfilling relationships and adaptation to changeadaptation to change

Mental Illness DefinitionMental Illness Definition

Any disorder that affects the mind or behaviorAny disorder that affects the mind or behaviorMaladaptation to stress with culturally age Maladaptation to stress with culturally age inappropriate thoughts, feelings and behaviorsinappropriate thoughts, feelings and behaviorsBehavioral or psychological syndrome with Behavioral or psychological syndrome with distress, disability & lossdistress, disability & lossMental illness has been applied to those who do Mental illness has been applied to those who do not conform to society. The “strange” or not conform to society. The “strange” or “different” i.e. Gandhi, Abraham Lincoln, Mother “different” i.e. Gandhi, Abraham Lincoln, Mother Teresa…Have all been independent thinkers Teresa…Have all been independent thinkers thus labeled different. So who are the mentally thus labeled different. So who are the mentally ill-anyone can have a mental illness.ill-anyone can have a mental illness.

Mental Health vs. Mental IllnessMental Health vs. Mental IllnessAdequate self conceptAdequate self conceptEffective copingEffective copingGood problem solving & Good problem solving &

decision makingdecision makingIndependentIndependentReality based thinkingReality based thinkingSets goalsSets goalsOptimisticOptimisticDelays gratificationDelays gratificationEffective socializationEffective socialization

Poor self concept Poor self concept Ineffective copingIneffective copingPoor problem solving & Poor problem solving &

decision makingdecision makingDependentDependentNonreality based Nonreality based thinkingthinking

Poor goal settingPoor goal settingPessimisticPessimisticImmediate gratificationImmediate gratificationPoor socializationPoor socialization

Myths about Mental IllnessMyths about Mental Illness

Mentally ill people are easily recognizedMentally ill people are easily recognized

Mentally ill people are dangerousMentally ill people are dangerous

Mental illness is inheritedMental illness is inherited

Mental illness can be predictedMental illness can be predicted

Mental illness is caused by internal forces Mental illness is caused by internal forces or maybe the devil!or maybe the devil!

Mental illness is incurableMental illness is incurable

Interdisciplinary/Interdisciplinary/MultidisciplinaryMultidisciplinary

Treatment Team Treatment Team Goal: Form & implement an individualized plan of care

for each client

Definition: A team of health care providers who together provide a holistic view of the client. Each member has a

specific role within the treatment planning of the client,

However some of the roles are duplicated such as providing therapeutic

communication

Examples of members:

Treatment Team membersTreatment Team members

PsychiatristPsychiatristPsychologistPsychologistNurse & nursing staffNurse & nursing staffCase ManagerCase ManagerCounselorCounselorSocial WorkerSocial WorkerRehabilitation SpecialistRehabilitation SpecialistOthersOthers

Psychiatrist

A medical doctor who prescribes treatment & is the head of the team. Responsible for medical diagnosis

Guidelines for making diagnosis found in:

DSM-IV-R Diagnostic Statistical Manual

4th edition revised

Diagnosis is made on a multiaxial system

MULTIAXIAL DIAGNOSISMULTIAXIAL DIAGNOSISUsed to assess several aspects of the clientUsed to assess several aspects of the client

Axis I-The Psychiatric Disorder i.e. DepressionAxis I-The Psychiatric Disorder i.e. DepressionAxis II-The Personality Disorder or Developmental Disorder / Axis II-The Personality Disorder or Developmental Disorder / deferred i.e. Antisocial Personality Disorderdeferred i.e. Antisocial Personality Disorder

Remaining 3 are not needed, but helpfulRemaining 3 are not needed, but helpful

Axis III-The Medical Diagnosis i.e. HypertensionAxis III-The Medical Diagnosis i.e. HypertensionAxis IV-Psychosocial or environmental problems i.e. financial Axis IV-Psychosocial or environmental problems i.e. financial problems, family conflictproblems, family conflictAxis V-Global Assessment FunctioningAxis V-Global Assessment Functioning

Global Assessment FunctioningGlobal Assessment Functioning

Is an indication of the client’s best level of Is an indication of the client’s best level of psychological, social and occupational psychological, social and occupational functioning during the preceding yearfunctioning during the preceding year

A score of 1 indicates persistent danger of A score of 1 indicates persistent danger of severely hurting oneself or others and 100 severely hurting oneself or others and 100 indicates superior functioningindicates superior functioning

See page 26 in your book for a complete See page 26 in your book for a complete scalescale

Treatment Team cont.Psychologist

Masters or doctorate prepared member who provides the client with psychological testing, behavioral plan, individual therapy/Psychotherapy, and Family Therapy

Nurse-offers a holistic view of the client & maintains care 24 hours a day 7 days a week

RN’s & LPN’s plus

Mental Health technicians/ Workers -non licensed nursing staff who provide direct care

Nursing StaffResponsible for maintaining a safe

therapeutic Milieu

Treatment Team Cont.

ANA Standards for Psychiatric ANA Standards for Psychiatric & Mental Health Nursing& Mental Health Nursing

Utilizing nursing Utilizing nursing process which process which includes identifying includes identifying outcomesoutcomes

CounselingCounseling

Milieu TherapyMilieu Therapy

Promotion of self-care Promotion of self-care activitiesactivities

Psychobiological Psychobiological InterventionsInterventions

Health teachingHealth teaching

Case ManagementCase Management

Health Promotion & Health Promotion & MaintenanceMaintenance

Advanced PracticeAdvanced PracticePsych nursesPsych nurses

PsychotherapyPsychotherapy

Prescriptive Authority & treatmentPrescriptive Authority & treatment

ConsultationConsultation

Psychiatric Nurse Practitioner &

Clinical Psychiatric Nurse Specialist

Nurses CareNurses Care

People want to know how much you People want to know how much you

CARECARE

Before they care how much you Before they care how much you

Know!Know!

Principles of CaringPrinciples of Caring

Patient centeredPatient centered

Accept the client-nonjudgmentalAccept the client-nonjudgmental

Need to express negative emotionsNeed to express negative emotions

Do not use a highly intelligent approachDo not use a highly intelligent approach

Be consistent. Be consistent.

Maintain a therapeutic not social Maintain a therapeutic not social relationshiprelationship

Caring cont.Caring cont.

Make no promises that you cannot keepMake no promises that you cannot keep

Always call the patient by the preferred Always call the patient by the preferred namename

Offer praise & sincere complimentsOffer praise & sincere compliments

Treat clients & family like you would want Treat clients & family like you would want to be treatedto be treated

StigmaStigma

““If I Had A Wish”If I Had A Wish”

Treatment Team cont.Treatment Team cont.Case ManagerCase Manager

Achieve managed care in hospital and Achieve managed care in hospital and communitycommunity

Coordinate client care on a broad continuum Coordinate client care on a broad continuum from insurance to legal to medical needsfrom insurance to legal to medical needs

Improve client access to resources within the Improve client access to resources within the communitycommunity

Coordinate care across fragmented health care Coordinate care across fragmented health care delivery systemsdelivery systems

Treatment Team cont. Treatment Team cont. Counselor

Masters or doctorate, focus is on counseling regarding Client needs i.e. addiction, family crisis,

Treatment Team Cont.Social Worker

Masters degree or doctorate; assists the client & support system in discharge planning.

Treatment Team cont.Treatment Team cont.

Rehabilitation specialists-focus is in a specialized area i.e. occupation, recreation

Others: Educational specialist, Art Therapist, Dietician, Music Therapist, Out patient

HISTORY OF MENTAL ILLNESSHISTORY OF MENTAL ILLNESS

ANCIENT BELIEFS: Hippocrates (400 BC)—ANCIENT BELIEFS: Hippocrates (400 BC)—disequilibrium of four humors (blood, black bile, yellow disequilibrium of four humors (blood, black bile, yellow bile, and phlegm)bile, and phlegm)

MIDDLE AGES (500-1500 AD): Europe=associated with MIDDLE AGES (500-1500 AD): Europe=associated with witchcraft and supernatural; “ship of fools” to search for witchcraft and supernatural; “ship of fools” to search for their lost rationalitytheir lost rationality

Middle Eastern Islamic: first asylums for mentally ill by Middle Eastern Islamic: first asylums for mentally ill by Moslems Moslems

• CHRISTIANITY (16CHRISTIANITY (16THTH-17-17THTH century): demon possessed; century): demon possessed; Rx by theologians and witch doctors; incarcerated in Rx by theologians and witch doctors; incarcerated in dungeons, beaten and starved; witch huntsdungeons, beaten and starved; witch hunts

HISTORY OF MENTAL ILLNESSHISTORY OF MENTAL ILLNESS

1751: Benjamin Franklin est. Pennsylvania Hospital in 1751: Benjamin Franklin est. Pennsylvania Hospital in Philadelphia: first institution in Us to treat MI.Philadelphia: first institution in Us to treat MI.

Dr Benjamin Rush: Father of American Psychiatry; Dr Benjamin Rush: Father of American Psychiatry; attempted to offer medical interventions (bloodletting, attempted to offer medical interventions (bloodletting, spinning chair, tranquilizer chairspinning chair, tranquilizer chair

1800’s: Dorothea Dix, school teacher, promoted State 1800’s: Dorothea Dix, school teacher, promoted State Hospitals; crusade was that MI should receive equal Hospitals; crusade was that MI should receive equal care to physical illnesscare to physical illness

1873: Linda Richards first American psychiatric nurse, 1873: Linda Richards first American psychiatric nurse, emphasized assessing physical and emotional needs. emphasized assessing physical and emotional needs. Established first School of Psychiatric NursingEstablished first School of Psychiatric Nursing

HISTORY OF MENTAL ILLNESSHISTORY OF MENTAL ILLNESS

1935: Insulin Shock Therapy developed1935: Insulin Shock Therapy developed

1936: Psychosurgery/Lobotomy popular thru 1950’s—1936: Psychosurgery/Lobotomy popular thru 1950’s—still used in Europestill used in Europe

1937: Electroconvulsive therapy (ECT) still used in US 1937: Electroconvulsive therapy (ECT) still used in US todaytoday

1950: National League of Nursing required psychiatric 1950: National League of Nursing required psychiatric nursing course in curriculumnursing course in curriculum

1952: Hildegard Peplau published theory on 1952: Hildegard Peplau published theory on Interpersonal Relations in NursingInterpersonal Relations in Nursing

1954: first tranquilizer/psychotropic medication 1954: first tranquilizer/psychotropic medication (Thorazine)(Thorazine)

HISTORY OF MENTAL ILLNESSHISTORY OF MENTAL ILLNESS

1963: Deinstitutionalization of State Hospitals1963: Deinstitutionalization of State Hospitals

1970: Mentally Ill Pt Bill of Rights approved by federal 1970: Mentally Ill Pt Bill of Rights approved by federal governmentgovernment

1973: ANA established Standards of Psych-mental 1973: ANA established Standards of Psych-mental health nursinghealth nursing

1990: declared Decade of the Brain—goal was to 1990: declared Decade of the Brain—goal was to discover cause of MI; ANA established Standards for discover cause of MI; ANA established Standards for child & adolescent mental health nursing & addictions child & adolescent mental health nursing & addictions nursingnursing

HISTORY OF MENTAL ILLNESSHISTORY OF MENTAL ILLNESS

2121stst Century: Healthy People 2010 goals: decrease in MI Century: Healthy People 2010 goals: decrease in MI & suicides, substance abuse; continue research of new & suicides, substance abuse; continue research of new medications with minimal SE, search for cause of MI; medications with minimal SE, search for cause of MI; insurance to pay for self help RX & effective de-stress insurance to pay for self help RX & effective de-stress techniques, increase in herbal medicine, increase in techniques, increase in herbal medicine, increase in preventive carepreventive care

West Virginia Mental Health crisis: admissions to mental West Virginia Mental Health crisis: admissions to mental hospitals increased 45% 1999-2003. Beds have hospitals increased 45% 1999-2003. Beds have decreased & spending has increased. Group homes decreased & spending has increased. Group homes have decreased & jail admissions have increased. In have decreased & jail admissions have increased. In 2005 Group Homes decreased in WV from 205 to 86.2005 Group Homes decreased in WV from 205 to 86.

HISTORY OF MENTAL ILLNESSHISTORY OF MENTAL ILLNESS

Recent Cabell County Substance Abuse health care Recent Cabell County Substance Abuse health care providers believe part of problem regarding substance providers believe part of problem regarding substance abuse is lack of accessible treatment. Law enforcement abuse is lack of accessible treatment. Law enforcement believed need more money spent with law enforcement believed need more money spent with law enforcement & jail system& jail system

Prevalence of Psychiatric Disorders in USPrevalence of Psychiatric Disorders in US

2.2 million people affected with Schizophrenia2.2 million people affected with Schizophrenia

18.8 million have Affective Disorder( Depression, 18.8 million have Affective Disorder( Depression, Bipolar) 19.1 million have Anxiety DisorderBipolar) 19.1 million have Anxiety Disorder

1 in 3 families affected with a mental illness (2006)1 in 3 families affected with a mental illness (2006)

Legal and ethicalLegal and ethical

Mentally Ill ClientsMentally Ill Clients

have the same rights as all have the same rights as all individualsindividuals

Rights of hospitalized clientRights of hospitalized clientExamples:Examples:

Right to dignityRight to dignity

Right to individualizedRight to individualized

treatmenttreatment

Right to voteRight to vote

Right to mailRight to mail

Right to worshipRight to worship

Right to legal counselRight to legal counsel

Right to informed Right to informed consentconsent

Right to visitorsRight to visitors

Right to be assessed Right to be assessed within a limited period within a limited period of time ( usually 72 of time ( usually 72 hours)hours)

Important Legal RightsImportant Legal Rights

ConfidentialityConfidentiality

Right to treatmentRight to treatment

Right to least restrictive treatment Right to least restrictive treatment

Right to refuse treatmentRight to refuse treatment

Right to ConfidentialityRight to Confidentiality

Nurses must maintain confidentialityNurses must maintain confidentialityBreach of confidentiality could cause termination Breach of confidentiality could cause termination of employment/expulsion from college programof employment/expulsion from college programLaw requires disclosure of info: suspected child Law requires disclosure of info: suspected child abuse(Nurses are mandated reporters), criminal abuse(Nurses are mandated reporters), criminal cases, government requests & public has the cases, government requests & public has the right to know (Duty to Warn & Protect)right to know (Duty to Warn & Protect)Stigma of being mentally ill makes need for Stigma of being mentally ill makes need for confidentiality greater than with manyconfidentiality greater than with many

physical illnesses.physical illnesses.

Right to TreatmentRight to Treatment

Legal courts uphold that mentally ill have Legal courts uphold that mentally ill have the right to fair and humane treatmentthe right to fair and humane treatment

Federal law mandates that all states must Federal law mandates that all states must provide mental health care. For example: provide mental health care. For example: State mental health facilitiesState mental health facilities

Client must be informed of the Client must be informed of the individualized treatment-commonly known individualized treatment-commonly known as Treatment Team meetingsas Treatment Team meetings

Right to Least Restrictive TreatmentRight to Least Restrictive Treatment

Examples:Examples:

Will receive the least amount of Will receive the least amount of medication that decreases symptomsmedication that decreases symptoms

Communication Medication Communication Medication

most restrictive-Seclusion &/restraintsmost restrictive-Seclusion &/restraints

Discharge to least restrictiveDischarge to least restrictive

environmentenvironment

Right to Refuse TreatmentRight to Refuse Treatment

Client has the right to refuse treatment if client is Client has the right to refuse treatment if client is not a threat to self or othersnot a threat to self or others

Cannot be kept hospitalized against his/her willCannot be kept hospitalized against his/her will

Physician & legal system can petition for Physician & legal system can petition for continued treatment if client is threat to self or continued treatment if client is threat to self or otherother

May need physician second opinion-example: May need physician second opinion-example: Paranoid client believes medication is poison & Paranoid client believes medication is poison & refuses the medsrefuses the meds

Ethical Issues often also legal Ethical Issues often also legal issuesissues

Nurse maintains ethics by following Nurse maintains ethics by following professional code of conduct established professional code of conduct established by the professional society-ANAby the professional society-ANA

Ethical situations often present with moral Ethical situations often present with moral issuesissues

Legal ethical componentsLegal ethical componentsmust always be must always be

consideredconsideredby the by the

professionalprofessionalnursenurse

CULTURAL ISSUESCULTURAL ISSUES

Learned behavior based on values, beliefs & perceptions Learned behavior based on values, beliefs & perceptions as established by cohesive groupas established by cohesive group

Reflected in food, religion, communication, personal Reflected in food, religion, communication, personal space, dress, level of independence, role expectationsspace, dress, level of independence, role expectations

ETHNICITY: sense of belonging to a cultural groupETHNICITY: sense of belonging to a cultural group

ETHNOCENTRISM: belief that one’s culture is superior ETHNOCENTRISM: belief that one’s culture is superior to anotherto another

STEREOTYPES: formulating a belief system based on STEREOTYPES: formulating a belief system based on negative biasesnegative biases

DISCRIMINATION: prejudice that is demonstrated thru DISCRIMINATION: prejudice that is demonstrated thru behavior (ageism, sexism, racism)behavior (ageism, sexism, racism)

CULTURAL ISSUESCULTURAL ISSUES

Caring for culturally diverse populations Caring for culturally diverse populations requires:requires:

Open-mindedness: allows nurse to be more sensitive Open-mindedness: allows nurse to be more sensitive about needsabout needs

Knowledge: educate self about cultureKnowledge: educate self about culture

Communicating: use interpreter or recognize level of Communicating: use interpreter or recognize level of English fluencyEnglish fluency

PSYCHOSOCIAL PSYCHOSOCIAL REHABILITATIONREHABILITATION

Teach individuals disabled by mental illness to Teach individuals disabled by mental illness to work & live independently, overcome blocks in work & live independently, overcome blocks in opportunity & motivation and follow regimens of opportunity & motivation and follow regimens of living likely to maintain or restore highest living likely to maintain or restore highest possible level of well-beingpossible level of well-being

Use eclectic/holistic approach to help persons Use eclectic/holistic approach to help persons with psychiatric disabilities become satisfied and with psychiatric disabilities become satisfied and successful in their environments with least successful in their environments with least amount of professional assistanceamount of professional assistance

PSYCHOSOCIAL REHABILITATIONPSYCHOSOCIAL REHABILITATIONTERTIARY PREVENTIONTERTIARY PREVENTION

teach persons disabled by MI to work & live teach persons disabled by MI to work & live independently, develop new skills & take medicationsindependently, develop new skills & take medications

NONCOMPLIANCENONCOMPLIANCE

Reasons: side effects, transportation, cost, stigma, lack Reasons: side effects, transportation, cost, stigma, lack family support, lifestyle (homeless)family support, lifestyle (homeless)

EMPOWERMENTEMPOWERMENT

Acceptance of what isAcceptance of what is

Responsibility for one’s experience of what isResponsibility for one’s experience of what is

Trust in one’s self & ability to make appropriate choicesTrust in one’s self & ability to make appropriate choices

LEVELS: Participation; choosing; supporting/relating; LEVELS: Participation; choosing; supporting/relating; negotiating; accessing resourcesnegotiating; accessing resources

TRADITIONAL VERSUS TRADITIONAL VERSUS PSYCHIATRIC REHABILITATIONPSYCHIATRIC REHABILITATION

FOCUSFOCUS

Disease, illness, Disease, illness, symptomssymptoms

BASISBASIS

DisabilitiesDisabilities

SETTINGSETTING

InstitutionInstitution

THERAPEUTIC THERAPEUTIC APPROACHAPPROACH

Expert to patientExpert to patient

FOCUSFOCUS

Wellness & healthWellness & health

BASISBASIS

Abilities & functional Abilities & functional behaviorsbehaviors

SETTINGSETTING

CommunityCommunity

THERAPEUTIC THERAPEUTIC APPROACHAPPROACH

Adult to adult Adult to adult

TRADITIONAL VERSUS TRADITIONAL VERSUS PSYCHIATRIC REHABILITATIONPSYCHIATRIC REHABILITATION

MEDICATIONMEDICATION

Medicate until symptoms Medicate until symptoms controlledcontrolled

DECISION MAKINGDECISION MAKING

Doctor makes decisions Doctor makes decisions & prescribes& prescribes

EMPHASISEMPHASIS

Dependence & Dependence & compliancecompliance

MEDICATIONMEDICATION

Medicate as appropriate. Medicate as appropriate. Must tolerate & control Must tolerate & control some symptomssome symptoms

DECISION MAKINGDECISION MAKING

Management in Management in partnership with patient partnership with patient

EMPHASISEMPHASIS

Strengths, self-help and Strengths, self-help and interdependenceinterdependence