Transcript Introduction to psychiatric Nursing

Introduction to
Psychiatric Nursing
Module 2: Concepts
RNSG 2213
History Concepts
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How were mentally ill treated prior to1790’s?
 Banishment
 Confinement
What were attitudes toward them?
 Possessed by the devil
 Lacked basic human qualities
St. Mary of Bethlehem Hospital, London
(“Bedlam”) Opened to lunatics 1403
Visitors pay for “entertainment”
History Concepts
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Period of Enlightenment begins in 1790’s
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Concept of “ Asylum” (sanctuary):
 If we treat patients humanely and
respectfully, they will improve.
 Mental illness worsens with stress
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First mental hospitals (“asylums”) in US in 1820’s
History Concepts
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Who was Dorthea Dix?
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A nurse who was one of the first major
reformers in the United States.
Helped develop the concept of an asylum
Direct role in opening 32 state hospitals
Dorthea Dix Asylum in North Carolina
Austin, Texas
State Insane Asylum 1851
Era of Psychotropic Drugs
 Medications first available in 1950s, i.e.
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chlorpromazine (Thorazine) for
Schizophrenia, Lithium for Mania
Hope for previously “incurable” mental
illnesses and enhanced quality of life.
Community Mental Health Movement
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Response to the overcrowding and bureaucracy
of public mental hospitals.
 Chronically mentally ill “warehoused” and
often abused, neglected
1963 Community Mental Health Act
 Concept: Patients can be treated better,
cheaper in community
Massive deinstitutionalization: All State Hospitals
in some states closed
Results: Increased acuity and strain on
emergency services, increased number
of homeless mentally ill
ETHICAL ASPECTS: SOCIAL VALUES
(Consider what effect each of these values has
on mental health care)
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Individual Freedom
Money
Paternalism vs Libertarianism
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Paternalism believes that an authority knows
what is best for you
Libertarianism believes that the individual knows
what is best for them
No other area of nursing is so affected by social
values as psychiatric nursing
A Nurse Needs to Know About:
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How to adapt legal principles to mental health
settings:
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safeguarding nursing practice from charges of
negligence, false imprisonment, assault, or battery
DUTY TO WARN
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Mental health professionals must warn others of a
client’s threat of suicide or of harm to self or
others
Rights of Psychiatric/Mental Health
Patients
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Right to refuse treatment
Right to informed consent ( and the right to
know about rights)
Right to confidentiality
Right to receive visitors and telephone
calls
Right to be treated with respect
Right to be treated in the least restrictive
environment
Client Rights
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Concept of Least Restrictive Environment:
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Should guide nursing decisions
Seclusion is used when the person is a danger to
others
Restraint is used when the person is a danger to
self
Never used to get a patient to comply
Rights of Mentally Ill Patients
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Basic Needs:
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Warmth: clothing a blanket
Food
Access to the outdoors
Contact with family, legal representative
Do NOT have right to all possessions
(When can access to possessions be restricted?)
Legal Aspects: Commitments
(As Applied under Texas Law)
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Mental illness as defined by the Texas Mental
Health Code
“Mental illness is a disease or condition which
either:
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Substantially impairs the person’s thought,
perception of reality, emotional process
and/or
Grossly impairs behavior as manifested by a
recent event of disturbed behavior (“Gravely
disabled”)
Commitments
Voluntary Commitment
 A person 16 years of age or over signs
themselves in for admission. Person is
advised of their rights under the code.
 4 Hour Rule: If a patient changes their mind
about being in the hospital, psychiatrist has 4
hours to file for a commitment.
 Signs a consent for treatment.
Commitments, cont’d
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Most commitments are voluntary where the
individual or the therapist request admission
and the patient meets criteria for admission
The patient must sign consents for all
psychotropic medications. Refusal to sign
these consents means the medications can
NOT be administered
Involuntary Commitments
Emergency Mental Illness Commitment
Allows Mental Health Deputies (Crisis
Intervention Team) to pick up a person who
presents an “IMMINENT DANGER TO SELF
OR OTHERS” and is “Gravely Disabled”
and bring them into custody for 24 HOURS.
 MD can begin commitment procedures (file)
at that time.
Involuntary Commitments,
cont’d
Order of Protective Custody (OPC)
 Commitment must be accompanied by a
medical certificate, which states that the
physician has examined the patient within 24
hours. Filed at the County Clerk’s Office.
 Probable Cause Hearing within 72 hrs.
 Pt. can be committed for 14 days.
Involuntary Commitments,
cont’d
Temporary Commitment
 Papers must be filed with the Court
 Hearing before a judge with physician and
patient present.
 Must prove “Danger to self or others” or
meets the deterioration standard
 Can be committed UP TO 90 DAYS.
 May be discharged any time staff believes pt.
is ready.
 May change to Outpatient Commitment
Involuntary Commitments, cont’d
Extended Mental Health Commitment
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Very strong evidence needed
Commitment is up to 1 year.
Last but not least . . . .
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All involuntary commitments can include
court-ordered medications
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All commitments discussed previously can
apply to Chemical Dependency
TREATMENT SETTINGS AND
THE CONTINUUM OF CARE
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Where do we see the mentally ill being
treated?
How do individuals enter the mental health
system?
Why is discharge planning so important?
PSYCHOTHERAPEUTIC
MANAGEMENT
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TOOLS ARE:
SELF  DRUGS  ENVIRONMENT
 Therapeutic Use of SELF (Nurse-Client
Relationship)
 DRUGS: Psychopharmacology
 ENVIRONMENT: Therapeutic Milieu
NURSE ON THE MENTAL
HEALTH TEAM
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Mental Health Team:
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Psychiatrist
Nursing staff: includes licensed nurse, tech
Psychiatric Social Worker
Psychologist
Therapeutic Recreation and Expressive Arts
personnel
Client and Family
Other: Substance abuse counselor, employment
specialist, dietician, etc.