Transcript Introduction to psychiatric Nursing

Introduction to Psychiatric
Nursing
Test Questions
• Legal Aspects: Commitments
• Assessment of the mental health client
– Mental Status Exam
Test Questions
• Assessment of the mental health client
Nurse/ patient relationship
Stages and Phases
– Communication Techniques
Neurobiology: Not on the Test
Test Questions
• Neurobiological Concepts
• Practice tests on Blackboard
Social Values
• Individual Freedom
• Money
• Paternalism vs Libertarianism
– 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 effected
by social values as psychiatric nursing
History Concepts
• Where were mentally ill kept doing
middle ages?
– Banishment
– confinement
• What were attitudes toward them?
– No better than wild animals
– Placed on display
HistoryConcepts
• Renaissance: beginning of rationality.
1790s
• First mental hospitals in US in 1820’s
– Liberal idea of getting them out of jail
– Who was Dorthea Dix?
• A nurse who was one of the first major
reformers in the United States.
• Helped develop the concept of an asylum
• Had a direct role in opening 32 state hospitals
Dorthea Dix Hospital in North
Carolina
History Continued
• Concept: if we treat patients humanely, and
respectfully, in a bucolic country setting, they
will improve.
– Unchained
– Clothed
– Aspired to the philosophy that mental illness
worsens with stress
• Massachusetts hospital had cure rate of 1/3,
1/3 improved and 1/3 stayed in hospital for
life.
Community Mental Health
• Hospitals became
overcrowded and
bureaucratic.
Patients treated
cruelly.
Medications were not
available until the
1950s
Clorpromazine
(Thorazine) for
Schizophrenia
Lithium for Mania
Community Mental Health
• 1963 Community Mental Health Act
passed
• Concept: Patients treated better in
community; de-instutionalization
begins
• All State Hospitals in some States
closed.
• Homelessness increased
Rights of Mental Patients
• Right to refuse treatment
• Right to informed consent
• Right to receive visitors and telephone
calls
• Right to be treated in the least restricted
environment (Seclusion; Restraint)
• Right to be treated with respect (must
always provide for basic needs)
• DO NOT have a right to ALL
Possesions
Rights of Mental Patients
• Least Restrictive Environment:
– How Nurses should think
– 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 Mental Patients
• Basic Needs:
–
–
–
–
Warmth: clothing a blanket
Food
Access to the outdoors
Contact with family
– When can this be restricted?
Legal Aspects: Commitments
• Mental illness as defined by the Mental
Health Code
• “Mental illness is a disease or condition
which either:
– Substantially impairs the person’s thought,
perception of reality, emotional process or;
– Grossly impairs behavior as manifested by
a recent event of disturbed behavior
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.
• If a patient changes their mind about
being in the hospital, staff have 4 hours
to file for a commitment.
• signs a consent to treat.
Voluntary Commitment
• Most commitments are voluntary where the
individual or the therapist requests admission
and the patient
• The patient must sign consents for all
psychotropic medications. If the refuse to
sign these consents the medications can NOT
be administered
• All involuntary commitments can include
court ordered medications.
Involuntary Commitments
• Emergency Mental Illness Commitment
• Allows Mental Health Deputies to pick
up a person who presents an
“IMMINENT DANGER TO SELF OR
OTHERS” and bring them into custody
for 24 HOURS.
• MD can file a commitment at that time.
Order of Protective Custody
• Commitment must be accompanied by
a medical certificate , which states that
the physician has examined the patient
within 24 hours. This is filed at the
County Clerks Office. There is a $300.
charge for this.
• Probable Cause Hearing within 72 hrs.
• Pt. can be committed for 14 days.
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 anytime staff
believes pt. is ready.
• Change to Out Patient commitment
Extended Mental Health
Commitment
• Very strong evidence needed
• Commitment is up to 1 year.
• All commitments discussed can apply
to Chemical Dependency
Assessment: Data Collection
• Legal Status: Back of chart
• Psychiatric Evaluation- 24 hours
• Psychosocial Assessment- PSA
• Psychological Testing
• Lab tests- the usual CBC, RPR.
– Medication Levels: Lithium, Depakote,
Tegretol
– Drug test on every patient
Mental Status Exam
• Appearance:
– Dress: Conservative, Desheveled,
Inappropriate
– Grooming: Clean, Unkempt
– Facial expression: Alert, Masklike
– Eye contact: Does or doesn't
– Motor behavior: Mannerisms, Statue like
– Gait: Steady, Staggering
– General Health: Well Nourished
MSE: Speech
• Pace
• Interruptions: steady flow, shuffling
• Volume
• Clarity: Pressured, Slurred
• Tone and Modulation: Altered, calm
Level of consciousness
• Sensorium(Altered, Drowsy, Confused,
Nonresponsive)
• General responsiveness to environment
(Distracted, able to sustain attention)
• Responds (Answers questions, follows
simple instructions)
Emotional State
• Mood: Anxious, depressed, sad, calm,
frightened, flat, angry
• Affect: Intense. appropriate, labile, full
range of emotions
Thought Process: Form
• Autistic thinking: individualized
associations from with Patient
• Blocking: unconscious interruptions in
train of thought
• Circumstantial: digression of
inappropriate thoughts into ideas
eventually reaching the desired goal
Thought Process: Form
• Confabulation: unconcious filling of
gaps in memory with imagined or
untrue experiences that the person
believes but have no basis in reality
• Flight of ideas: Speech pattern is rapid
with no transition from topic to topic
• Fragmentation
Thought Process: Form, Cont.
• Loose associations: pattern of speech in
which a person's ideas slip of track onto
a topic that is unrelated
• Neologisms: New words created by the
patient
• Perseverate: repetition of the same
word or idea in response to different
questions
• Tangential: inability to have goaldirected associations of thoughts
• Word salad: incoherent mixture of
word or phrases
• Echolalia
Thought Content: Theme
• Somatic symptoms
• Rituals-Repetitive thinking or behavior
• Destructive-Violence, suicide or
Homicide
• Defensive-Delusions, hallucinations,
distortions in perception, excessive
ambivalence
Cognitive Functioning
• Oriented: Time, place person and
situation
• Attention and concentration
– Digit span exercise
– simple arithmetic
• Memory: Recent and Remote
• General Intelligence: Name 2 presidents
– days of the week
Cognitive Functioning, Cont.
• Abstract thinking: “A stitch in time
saves nine.”
What does this mean?
Concrete thinking: “If it is torn you sew it
up”
Abstract thinking: “If you take care of a
problem right away it does not get
bigger”
Cognitive Functioning, Cont.
• Insight and
Judgment:
• Is Patient safe?
– Can ask problem
solving question
• What would you do
if a pipe broke in the
house and water
was coming out?
• What would you do
if you saw a small
child on the end of a
dock by a lake?
Cognitive Functioning, Cont
• Perceptions and
Coordination:
• Ask client to write
name.
• Ask Client to draw a
circle
• Tests ability to
follow a simple
command, fine
motor skills, ability
to assimilate and
transfer information
Nursing Assessment
• How does pt. interact on unit?
• Does Pt. attend groups?
• Pt. have visitors, see Dr.. etc..
• Employment history, marital status
• Physical Assess; VS, Meds,
• Sleep disturbance
• Nutritional status
• Physical illness/drug abuse
Nurse Patient Relationship
• Relationship is a partnership
• Holistic View: treat body, mind, spirit
• Emphasizes self-care and responsibility
• Individual seen in context of family and
community
• THERAPEUTIC USE OF SELF
• 3 rules of psychotherapy
What is psychotherapy?
• Modifies thoughts, feelings and
behavior in the context of a therapeutic
relationship
• How is the Nurse Patient relationship
different than a friendship?
3 Phases of Nurse Patient
Relationship: Orientation
• Time when Nurse and Patient introduce
themselves and nurse defines limits and
boundaries of the relationship. Make a
verbal contract.
• Confidentiality must be discussed
• Can not keep “secrets”
• Student Nurse examine own feelings;
issues of self disclosure must be clear.
Goal is TRUST
Working Phase
• Pt. begins to share concerns with the
nurse.
• Pt. will talk about session before and tie
it in.
• Phase may happen immediately or not
at all.
Termination Phase
• Patient and nurse review relationship
• Often pt. feels free to share more.
• Feelings: sad, relieved, angry, anxious
• May ignore event altogether
Issues in the N/PT
Relationship
• Transference: Phenomenon of
projection of thoughts, feelings, and
wishes onto the nurse who has come to
represent a figure from the patients
past.
• Occurs in all relationships.
• Usually same sex parent
• Overreactions of pts. usually
transference.
Countertransference
• When Pt. represents someone from the
nurses past.
• Identified by an overreaction on the
part of the nurse.
• Can be a part of the self that nurse does
not like. Example would be not liking a
patients indecision or dependence.
• Alcoholism can cause strong feelings.
Other Factors
• Countertransference issues are best
dealt with by clinical supervision.
• For students; tell instructor
• Rescue fantasy: Common response of
nursing and medical students. Don’t
expect too much of yourselves or your
patient.
Effective Helpers
• Empathy: Process that allows a person
for that moment in time to really see the
situation from that persons’ perspective
• A healing moment
• Doesn’t include pity.
• Sympathy: Assumption that your
situation parallels the pts. “I’m a
mother, I understand”
Review of Communication
• Which has more impact; verbal or nonverbal communication. Body language.
• Describe the components of non-verbal
• Nonverbal communication must be
verified
• Advantages of open ended and close
ended questions.
• What is proxemics
Common Mistakes: Making
Assumptions, Crossing
Boundaries
• Patient states:”My child is getting on
my nerves, sometimes I yell at him
alot.”
• Student: “I know what you mean. I yell
at my children too.
Conveying personal value
judgements
• Pt. “My doctor says I’m going home
tomorrow”
• Student: “That’s great”
Suggestive Questions
• Student: “Did you have a good time on
your pass last weekend?”
• Pt. “Yes”
Avoid asking “why”
• Your patient has made a suicide
attempt by cutting his wrists very
deeply. It is you first encounter. After
introductions, the students asks:
• “Why did you cut your wrists?”
Clarifies indefinite pronouns
• Patient. “They are scaring me”
• Student. “There is nothing to worry
about”
Concepts of Communication
• Utilize your knowledge of the patients illness
when communicating.
• Example: Manic patients need focusing
questions, not open ended questions.
• Listen and respond to pts. Statements
• Example: “I don’t like being here at the
hospital” St.“What is it you don’t like ?”
• “Here and now” better than past or future