1. Introduction to Psychiatric Nursing

2. Test Questions Legal Aspects: CommitmentsLegal Aspects: Commitments Assessment of the mental health clientAssessment of the mental health client –Mental Status Exam

3. Test Questions Assessment of the mental health clientAssessment of the mental health client Nurse/ patient relationship Stages and Phases –Communication Techniques

4. Neurobiology: Not on the Test

5. Test Questions Neurobiological ConceptsNeurobiological Concepts Practice tests on BlackboardPractice tests on Blackboard

6. Social Values Individual FreedomIndividual Freedom MoneyMoney Paternalism vs LibertarianismPaternalism 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 nursingNo other area of nursing is so effected by social values as psychiatric nursing

7. History Concepts Where were mentally ill kept doing middle ages?Where were mentally ill kept doing middle ages? –Banishment –confinement What were attitudes toward them?What were attitudes toward them? –No better than wild animals –Placed on display

8. HistoryConcepts Renaissance: beginning of rationality.Renaissance: beginning of rationality.1790s First mental hospitals in US in 1820’sFirst 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.A nurse who was one of the first major reformers in the United States. Helped develop the concept of an asylumHelped develop the concept of an asylum Had a direct role in opening 32 state hospitalsHad a direct role in opening 32 state hospitals

9. Dorthea Dix Hospital in North Carolina

10. History Continued Concept: if we treat patients humanely, and respectfully, in a bucolic country setting, they will improve.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.Massachusetts hospital had cure rate of 1/3, 1/3 improved and 1/3 stayed in hospital for life.

11. Community Mental Health Hospitals became overcrowded and bureaucratic. Patients treated cruelly.Hospitals became overcrowded and bureaucratic. Patients treated cruelly. Medications were not available until the 1950s Clorpromazine (Thorazine) for Schizophrenia Lithium for Mania

12. Community Mental Health 1963 Community Mental Health Act passed1963 Community Mental Health Act passed Concept: Patients treated better in community; de-instutionalization beginsConcept: Patients treated better in community; de-instutionalization begins All State Hospitals in some States closed.All State Hospitals in some States closed. Homelessness increasedHomelessness increased

13. Rights of Mental Patients Right to refuse treatmentRight to refuse treatment Right to informed consentRight to informed consent Right to receive visitors and telephone callsRight to receive visitors and telephone calls Right to be treated in the least restricted environment (Seclusion; Restraint)Right to be treated in the least restricted environment (Seclusion; Restraint) Right to be treated with respect (must always provide for basic needs)Right to be treated with respect (must always provide for basic needs) DO NOT have a right to ALL PossesionsDO NOT have a right to ALL Possesions

14. Rights of Mental Patients Least Restrictive Environment: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

15. Rights of Mental Patients Basic Needs:Basic Needs: –Warmth: clothing a blanket –Food –Access to the outdoors –Contact with family –When can this be restricted?

16. Legal Aspects: Commitments Mental illness as defined by the Mental Health CodeMental illness as defined by the Mental Health Code “Mental illness is a disease or condition which either:“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

17. Commitments Voluntary CommitmentVoluntary Commitment A person 16 years of age or over signs themselves in for admission. Person is advised of their rights under the code.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. 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.signs a consent to treat.

18. Voluntary Commitment Most commitments are voluntary where the individual or the therapist requests admission and the patientMost 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 administeredThe 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.All involuntary commitments can include court ordered medications.

19. Involuntary Commitments Emergency Mental Illness CommitmentEmergency 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.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.MD can file a commitment at that time.

20. 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.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.Probable Cause Hearing within 72 hrs. Pt. can be committed for 14 days.Pt. can be committed for 14 days.

21. Temporary Commitment Papers must be filed with the CourtPapers must be filed with the Court Hearing before a judge with physician and patient present.Hearing before a judge with physician and patient present. Must prove “Danger to self or others”or meets the deterioration standardMust prove “Danger to self or others”or meets the deterioration standard Can be committed UP TO 90 DAYS.Can be committed UP TO 90 DAYS. May be discharged anytime staff believes pt. is ready.May be discharged anytime staff believes pt. is ready. Change to Out Patient commitmentChange to Out Patient commitment

22. Extended Mental Health Commitment Very strong evidence neededVery strong evidence needed Commitment is up to 1 year.Commitment is up to 1 year. All commitments discussed can apply to Chemical DependencyAll commitments discussed can apply to Chemical Dependency

23. Assessment: Data Collection Legal Status: Back of chartLegal Status: Back of chart Psychiatric Evaluation- 24 hoursPsychiatric Evaluation- 24 hours Psychosocial Assessment- PSAPsychosocial Assessment- PSA Psychological TestingPsychological Testing Lab tests- the usual CBC, RPR.Lab tests- the usual CBC, RPR. –Medication Levels: Lithium, Depakote, Tegretol –Drug test on every patient

24. Mental Status Exam Appearance: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

25. MSE: Speech PacePace Interruptions: steady flow, shufflingInterruptions: steady flow, shuffling VolumeVolume Clarity: Pressured, SlurredClarity: Pressured, Slurred Tone and Modulation: Altered, calmTone and Modulation: Altered, calm

26. Level of consciousness Sensorium(Altered, Drowsy, Confused, Nonresponsive)Sensorium(Altered, Drowsy, Confused, Nonresponsive) General responsiveness to environment (Distracted, able to sustain attention)General responsiveness to environment (Distracted, able to sustain attention) Responds (Answers questions, follows simple instructions)Responds (Answers questions, follows simple instructions)

27. Emotional State Mood: Anxious, depressed, sad, calm, frightened, flat, angryMood: Anxious, depressed, sad, calm, frightened, flat, angry Affect: Intense. appropriate, labile, full range of emotionsAffect: Intense. appropriate, labile, full range of emotions

28. Thought Process: Form Autistic thinking: individualized associations from with PatientAutistic thinking: individualized associations from with Patient Blocking: unconscious interruptions in train of thoughtBlocking: unconscious interruptions in train of thought Circumstantial: digression of inappropriate thoughts into ideas eventually reaching the desired goalCircumstantial: digression of inappropriate thoughts into ideas eventually reaching the desired goal

29. Thought Process: Form Confabulation: unconcious filling of gaps in memory with imagined or untrue experiences that the person believes but have no basis in realityConfabulation: 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 topicFlight of ideas: Speech pattern is rapid with no transition from topic to topic FragmentationFragmentation

30. Thought Process: Form, Cont. Loose associations: pattern of speech in which a person's ideas slip of track onto a topic that is unrelatedLoose 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 patientNeologisms: New words created by the patient Perseverate: repetition of the same word or idea in response to different questionsPerseverate: repetition of the same word or idea in response to different questions

31. Tangential: inability to have goal- directed associations of thoughtsTangential: inability to have goal- directed associations of thoughts Word salad: incoherent mixture of word or phrasesWord salad: incoherent mixture of word or phrases EcholaliaEcholalia

32. Thought Content: Theme Somatic symptomsSomatic symptoms Rituals-Repetitive thinking or behaviorRituals-Repetitive thinking or behavior Destructive-Violence, suicide or HomicideDestructive-Violence, suicide or Homicide Defensive-Delusions, hallucinations, distortions in perception, excessive ambivalenceDefensive-Delusions, hallucinations, distortions in perception, excessive ambivalence

33. Cognitive Functioning Oriented: Time, place person and situationOriented: Time, place person and situation Attention and concentrationAttention and concentration –Digit span exercise –simple arithmetic Memory: Recent and RemoteMemory: Recent and Remote General Intelligence: Name 2 presidentsGeneral Intelligence: Name 2 presidents –days of the week

34. 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”

35. Cognitive Functioning, Cont. Insight and Judgment:Insight and Judgment: Is Patient safe?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 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?What would you do if you saw a small child on the end of a dock by a lake?

36. Cognitive Functioning, Cont Perceptions and Coordination:Perceptions and Coordination: Ask client to write name.Ask client to write name. Ask Client to draw a circleAsk Client to draw a circle Tests ability to follow a simple command, fine motor skills, ability to assimilate and transfer informationTests ability to follow a simple command, fine motor skills, ability to assimilate and transfer information

37. Nursing Assessment How does pt. interact on unit?How does pt. interact on unit? Does Pt. attend groups?Does Pt. attend groups? Pt. have visitors, see Dr.. etc..Pt. have visitors, see Dr.. etc.. Employment history, marital statusEmployment history, marital status Physical Assess; VS, Meds,Physical Assess; VS, Meds, Sleep disturbanceSleep disturbance Nutritional statusNutritional status Physical illness/drug abusePhysical illness/drug abuse

38. Nurse Patient Relationship Relationship is a partnershipRelationship is a partnership Holistic View: treat body, mind, spiritHolistic View: treat body, mind, spirit Emphasizes self-care and responsibilityEmphasizes self-care and responsibility Individual seen in context of family and communityIndividual seen in context of family and community THERAPEUTIC USE OF SELFTHERAPEUTIC USE OF SELF 3 rules of psychotherapy3 rules of psychotherapy

39. What is psychotherapy? Modifies thoughts, feelings and behavior in the context of a therapeutic relationshipModifies thoughts, feelings and behavior in the context of a therapeutic relationship How is the Nurse Patient relationship different than a friendship?How is the Nurse Patient relationship different than a friendship?

40. 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.Time when Nurse and Patient introduce themselves and nurse defines limits and boundaries of the relationship. Make a verbal contract. Confidentiality must be discussedConfidentiality must be discussed Can not keep “secrets ” Can not keep “secrets ” Student Nurse examine own feelings; issues of self disclosure must be clear. Goal is TRUSTStudent Nurse examine own feelings; issues of self disclosure must be clear. Goal is TRUST

41. Working Phase Pt. begins to share concerns with the nurse.Pt. begins to share concerns with the nurse. Pt. will talk about session before and tie it in.Pt. will talk about session before and tie it in. Phase may happen immediately or not at all.Phase may happen immediately or not at all.

42. Termination Phase Patient and nurse review relationshipPatient and nurse review relationship Often pt. feels free to share more.Often pt. feels free to share more. Feelings: sad, relieved, angry, anxiousFeelings: sad, relieved, angry, anxious May ignore event altogetherMay ignore event altogether

43. 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.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.Occurs in all relationships. Usually same sex parentUsually same sex parent Overreactions of pts. usually transference.Overreactions of pts. usually transference.

44. Countertransference When Pt. represents someone from the nurses past.When Pt. represents someone from the nurses past. Identified by an overreaction on the part of the nurse.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.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.Alcoholism can cause strong feelings.

45. Other Factors Countertransference issues are best dealt with by clinical supervision.Countertransference issues are best dealt with by clinical supervision. For students; tell instructorFor students; tell instructor Rescue fantasy: Common response of nursing and medical students. Don’t expect too much of yourselves or your patient.Rescue fantasy: Common response of nursing and medical students. Don’t expect too much of yourselves or your patient.

46. Effective Helpers Empathy: Process that allows a person for that moment in time to really see the situation from that persons’ perspectiveEmpathy: Process that allows a person for that moment in time to really see the situation from that persons’ perspective A healing momentA healing moment Doesn’t include pity.Doesn’t include pity. Sympathy: Assumption that your situation parallels the pts. “I’m a mother, I understand”Sympathy: Assumption that your situation parallels the pts. “I’m a mother, I understand”

47. Review of Communication Which has more impact; verbal or non- verbal communication. Body language.Which has more impact; verbal or non- verbal communication. Body language. Describe the components of non-verbalDescribe the components of non-verbal Nonverbal communication must be verifiedNonverbal communication must be verified Advantages of open ended and close ended questions.Advantages of open ended and close ended questions. What is proxemicsWhat is proxemics

48. Common Mistakes: Making Assumptions, Crossing Boundaries Patient states:”My child is getting on my nerves, sometimes I yell at him alot.”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.Student: “I know what you mean. I yell at my children too.

49. Conveying personal value judgements Pt. “My doctor says I’m going home tomorrow”Pt. “My doctor says I’m going home tomorrow” Student: “That’s great”Student: “That’s great”

50. Suggestive Questions Student: “Did you have a good time on your pass last weekend?”Student: “Did you have a good time on your pass last weekend?” Pt. “Yes”Pt. “Yes”

51. 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: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?”“Why did you cut your wrists?”

52. Clarifies indefinite pronouns Patient. “They are scaring me”Patient. “They are scaring me” Student. “There is nothing to worry about”Student. “There is nothing to worry about”

53. Concepts of Communication Utilize your knowledge of the patients illness when communicating.Utilize your knowledge of the patients illness when communicating. Example: Manic patients need focusing questions, not open ended questions.Example: Manic patients need focusing questions, not open ended questions. Listen and respond to pts. StatementsListen and respond to pts. Statements Example: “I don’t like being here at the hospital” St.“What is it you don’t like ?”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“Here and now” better than past or future