Introduction to Psychiatric/Mental Health Nursing
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| Mental Health | adaptation to stressors
Age appropriate adaptation and within social norms?
Occupational problem; physical function?
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| Mental Illness | (opposite) maladaptive responses to stressors
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| 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
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| 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
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| Mental Health nurses help people by | Through the therapeutic use of self, via therapeutic relationships & communication, nurses help people adapt, change, and grow.
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| 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!
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| 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)
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| 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
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| 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
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| Behavioral Therapy | (Behavioral Modification) teaches patients to refrain from acting on the inappropriate thoughts
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| 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
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| AXIS I | Major Clinical Disorders
real serious psych diagnosis
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| AXIS II | Personality Disorders
Mental Retardation
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| AXIS III | General Medical Conditions
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| AXIS IV | Psychosocial & Environmental Stressors
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| AXIS V | Scale 1 - 100: Global Assessment of Functioning
Score below 75 generally requires treatment, and insurance will likely pay for it.
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| AXIS I Major Psychiatric Disorders Examples: | Bipolar Disorder
Schizophrenia
Generalized Anxiety Disorder
Alcohol Dependence
Major Depression
Post-Traumatic Stress Disorder
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| Axis II Diagnoses Examples: | Borderline Personality Disorder
Antisocial Personality Disorder
Schizotypal Personality Disorder
Narcissistic Personality Disorder
Obsessive-Compulsive Personality Disorder
Mental Retardation
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| Axis III Diagnoses Examples: | Arthritis
Head trauma, remote
Colitis
Hepatitis
Diabetes
Hypertension
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| Axis IV Diagnoses Examples: | Illness in the Family
Financial Problems
Living Alone
Unemployment
Homelessness
Lack of Transportation
Recent Arrest
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| 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
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| 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
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| Beneficence | duty to benefit or promote the good of others
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| 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
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| Justice | people to be treated equal & fairly
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| Veracity | duty to be truthful
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| 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
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| 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.
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| 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
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| Informed Consent | Informed Consent
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| Restraints & Seclusion | Verbal Intervention -Chemical Restraints
Chemical restraints are considered less restrictive than physical restraints
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| False Imprisonment | Deliberate or unauthorized confinement; for instance if not a threat to self or others
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| Voluntary Commitment | have the right to check themselves out
2 of 3 admissions are voluntary in the general psychiatric;
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| 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
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| 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.
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| 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
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| 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
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| Mental Status Assessment | Holistic Nursing
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| 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
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| General Person history | Name
Martial status
Religious affiliations
Occupation
Education
Racial & ethnic status
Living arrangements
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| Relevant personal history | Previous illness & hospitalizations
Growth & development patterns
Social patterns
Sexual patterns
Interests
Substance abuse
Stress coping means
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| Relevant family history | Childhood or adolescence drug use/abuse
Physical, emotional, or sexual abuse
Family physical or mental problems
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| Psychiatric Assessment | Always Send Mail Through the Post Office
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| Always Send Mail Through the Post Office | Appearance
Speech
Memory/mood
Thoughts
Perception
Orientation
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| Purpose of Mental Status Examination (MSE) | Assessment of Emotional & Cognitive Functioning:
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| Assessment of Emotional & Cognitive Functioning: | Consciousness
Language
-Speech patterns slow or rapid; monotone; inappropriate; sarcastic tones; stuttering;
-Orientation
-Mood & Affect
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| Assessment Attention |
Memory
Abstract Reasoning
Thought Process/Content
Perceptions
Can they pay attention or do they change subject?
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| 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
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| Components of MSE | Appearance
Behavior
Cognition
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| 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
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| 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
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| inappropriate affect | not congruent with mood
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| 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
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| 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
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| Delusions | beliefs of something that is happening that really isnt, and they are involved in it
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| 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
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| 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.
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| Mini Mental State Exam | Assess cognitive functioning
Scores between 24 & 30 indicate No Cognitive Impairment
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| 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
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| Psychosocial Assessment hx | Previous hospitalizations
Past Medications
Sexual history
Family history
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| 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
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| Nursing Assessment of Anger & Aggression | Past & Present Hx
background information, culture & childhood environment
-Assess usual coping methods
-Assess meaning of current situation to patient
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| 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).
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| Common anger Nursing Diagnosis | Powerlessness
Spiritual Distress
Disturbed Thought Process
Risk for Violence (self or others, or both)
Appendix C
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