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Introduction to Psychiatric/Mental Health Nursing

Mental Health adaptation to stressors Age appropriate adaptation and within social norms? Occupational problem; physical function?
Mental Illness (opposite) maladaptive responses to stressors
Mental Health & Illness Continuum What are the nurse's thoughts & feelings of a person with a Mental Illness? How is Mental Illness portrayed in U.S. Culture? Homeless; locked up They are often pretty normal when on their meds
History of Mental Health Care in America Insane Asylum/Isolation from society Abusive Treatment Deinstitutionalization and Community Services Law Enforcement and the Mental Health Population Financial Factors Treatment Overview Hope
Mental Health nurses help people by Through the therapeutic use of self, via therapeutic relationships & communication, nurses help people adapt, change, and grow.
Mental Health Nursing Assumptions & Beliefs Everyone deserves respect. Everyone is capable of changing. Everyone has similar basic human needs. Everyone has the right to participate in their own care, IF THEY ARE SAFE IN DOING SO!
Mental Health Nursing Practice (ANA Definition): Promote & foster health Assess dysfunction Assist patients to regain or improve their coping abilities, maximizes strength & prevent further disability Nursing Diagnosis – NANDA (North American Nursing Diagnosis Association)
What do Psychiatric Nurses Do? Milieu Therapy – Thrputic Envrnmnt Setting itself maybe therapeutic for pt Counseling Intrvnts Promotion of Self-Care Act Psychobiological Treatments - Meds Teaching how to take and when to take meds Health Teaching Case Mgt Health Promot & Main
Cognitive Therapy teaches patients to control disorganized thoughts -- emotional disorders require this – pt needs to be able to recognize that they are thinking about something that is not correct or appropriate
Behavioral Therapy (Behavioral Modification) teaches patients to refrain from acting on the inappropriate thoughts
DSM-IV-TR Diagnostic & Statistical Manual of Mental Disorders A multi-axial evaluation system-5 Used to diagnose mental illness. Contains Diagnostic Criteria for each mental disorder. Axis completed by the admitting HCP – documented w/a phy hx
AXIS I Major Clinical Disorders real serious psych diagnosis
AXIS II Personality Disorders Mental Retardation
AXIS III General Medical Conditions
AXIS IV Psychosocial & Environmental Stressors
AXIS V Scale 1 - 100: Global Assessment of Functioning Score below 75 generally requires treatment, and insurance will likely pay for it.
AXIS I Major Psychiatric Disorders Examples: Bipolar Disorder Schizophrenia Generalized Anxiety Disorder Alcohol Dependence Major Depression Post-Traumatic Stress Disorder
Axis II Diagnoses Examples: Borderline Personality Disorder Antisocial Personality Disorder Schizotypal Personality Disorder Narcissistic Personality Disorder Obsessive-Compulsive Personality Disorder Mental Retardation
Axis III Diagnoses Examples: Arthritis Head trauma, remote Colitis Hepatitis Diabetes Hypertension
Axis IV Diagnoses Examples: Illness in the Family Financial Problems Living Alone Unemployment Homelessness Lack of Transportation Recent Arrest
Axis V Diagnoses: Number corresponding to the level at which the physician, NP, PA, Psychologist sees the patient functioning in daily life. Scale from 1 to 100: 100 best 1 worst Score > 75 generally requires treatment, and ins will likely pay If two # current/pa
Autonomy making independent choices. – the seriously mentally ill, or if a risk to harm to themselves or others, they have lost their right to make autonomous decisions
Beneficence duty to benefit or promote the good of others
Nonmaleficence do no harm -need to seclude so they don’t harm others; restraints so that they don’t harm themselves; help them learn and grow from their mistakes
Justice people to be treated equal & fairly
Veracity duty to be truthful
Ethical & Legal Issues in Psychiatric/Mental Health Nursing Rights The Pts Right to Refuse Medication: Exceptions: DTS or DTO (Danger To Self or Danger To Others) Reasonable medication to benefit patient Patient incompetence
Restrictive treatments Patient has the Right to the LEAST Restrictive TX alternative Make sure that it doesn’t over medicate them; make sure that it calms them rather than puts them to sleep if giving to patient against their will.
Confidentiality & Right to Privacy Cannot share information with parents of adolescent or child patients without their consent. The exceptions are if they threaten suicide, homicide; if advised of illegal drug abuse or drug use. There is a duty to report to the team
Informed Consent Informed Consent
Restraints & Seclusion Verbal Intervention -Chemical Restraints Chemical restraints are considered less restrictive than physical restraints
False Imprisonment Deliberate or unauthorized confinement; for instance if not a threat to self or others
Voluntary Commitment have the right to check themselves out 2 of 3 admissions are voluntary in the general psychiatric;
Involuntary Commitment Emergency Situation -Mentally ill person in need of observation, treatment or Gravely Disabled COE court ordered evaluation – COT court ordered treatment pts can’t have any sedating meds for 72 hours prior to court date
Gravely disabled unable to take care of their basic needs; if there was an emergency situation, they would not be mentally able to respond to that emergency or even recognize it.
Types of lawsuits that occur in psychiatric nursing: Breach of Confidentiality Invasion of Privacy Cannot search without cause Defamation of Character Libel - written Slander - spoken
Nursing Actions to Avoid Liability Practice within your Scope of Practice. Observe Policy manuals. Always put the pt first. Develop a good interpersonal relationship with pt and family. Comply with the Standard of Care. Adhere to the Nursing Process. Objective Documentation. F/up
Mental Status Assessment Holistic Nursing
Basic Psychiatric Assessment Presenting problem Why is the patient seeking help? Recent difficulties Increased feelings of: Depression Anxiety Confusion Hopelessness Suspiciousness Being overwhelmed Somatic changes
General Person history Name Martial status Religious affiliations Occupation Education Racial & ethnic status Living arrangements
Relevant personal history Previous illness & hospitalizations Growth & development patterns Social patterns Sexual patterns Interests Substance abuse Stress coping means
Relevant family history Childhood or adolescence drug use/abuse Physical, emotional, or sexual abuse Family physical or mental problems
Psychiatric Assessment Always Send Mail Through the Post Office
Always Send Mail Through the Post Office Appearance Speech Memory/mood Thoughts Perception Orientation
Purpose of Mental Status Examination (MSE) Assessment of Emotional & Cognitive Functioning:
Assessment of Emotional & Cognitive Functioning: Consciousness Language -Speech patterns slow or rapid; monotone; inappropriate; sarcastic tones; stuttering; -Orientation -Mood & Affect
Assessment Attention Memory Abstract Reasoning Thought Process/Content Perceptions Can they pay attention or do they change subject?
Assessment Pt. Appendix D in txtbook -Develop rapport -Obtain patient perspective -Observe behavior -Gather psychosocial data -Assess current level of functioning -Assess target symptoms -Formulate a Plan of Care -Support system
Components of MSE Appearance Behavior Cognition
Appearance Slumped super erect Posture / Body Movements Dress – appropriate for weather, situation Very flamboyant clothing – maybe manic episode Grooming & Hygiene Excessive makeup; clothes dirty; fingernails dirty; body odor; hair neat or matted
Behavior LOC Facial Expressions Speech Mood & Affect Cooperative/uncooperative; irritable; fearful; euphoric; Are facial expressions congruent with mood? Flat affect – not expressive blunted affect – slow to respond to emotion inappropriate affect
inappropriate affect not congruent with mood
Cognition Orientation (time, place & person) Attention Span Easily distracted? Recent /Remote Memory Judgment – ability to solve problems Are they aware of the consequences of their decisions Coping mechanisms used
Thought Process/Perceptions/content Shift from one idea to another very rapidly; assess for hallucinations that can be effecting their thought process; sights; sounds; smells; tactile hallucinations Thought Content – ideas and beliefs that are often not real Delusions
Delusions beliefs of something that is happening that really isnt, and they are involved in it
Screening for Suicidal Thoughts Death themes in art jokes writings Have you ever felt so blue that you felt like hurting yourself? Do you feel like hurting yourself now? Do you have a plan to hurt yourself? What would happen if you were dead? How would others react if you were dead
Clues of Suicide Risks Saying goodbye, giving away possessions. Prior Attempts Depression / Hopelessness Social Withdrawal Self-Mutilation Anorexia Verbal messages of defeat, failure, worthlessness & giving up. Death themes in art, jokes or writing.
Mini Mental State Exam Assess cognitive functioning Scores between 24 & 30 indicate No Cognitive Impairment
Psychosocial Assessment Obtain Information Regarding: Perceptions & expectations Recent stressors Somatic changes (body) Past & current medications Coping patterns Support system Substance use Self-esteem LOFunctioning Strengths & weaknesses Cultural & spiritual belie
Psychosocial Assessment hx Previous hospitalizations Past Medications Sexual history Family history
MSE Special Considerations Child Assessment: Denver II Screening Test   Aging Adult Assessment: Glasgow Coma Scale   Cultural Considerations Many behaviors we may view as a little off may be due to another cultural norm  
Nursing Assessment of Anger & Aggression Past & Present Hx background information, culture & childhood environment -Assess usual coping methods -Assess meaning of current situation to patient
Identify s/sx of anxiety/irritation before it escalates increased volume & rate of speech, rigid posture, increased demands, irritability, frowning, reddened face, pacing and/or twisting, jaw clenching, fists, wringing hands, staring with narrowed eyes into the eyes of another (crazy eyes).
Common anger Nursing Diagnosis Powerlessness Spiritual Distress Disturbed Thought Process Risk for Violence (self or others, or both) Appendix C
Created by: mgyger