Psych Exam 1 LECTURE PPT CHAPTER NOTES PDF

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PSYCH MENTAL NURSING LECTURE NOTES FOR UNITS 1, 2, AND 3. FOR EXAM 1....

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THE BASICS Chapter 1 – MEDS, MILIEU, AND MORE

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 Role of the Psychiatric Nurse  Promotes atmosphere of: o Respect Safety o Flexibility Open communication o Predictability Active involvement Case Management  Advocate  Establish and maintain ongoing relationship  Rapid assessment  Plan rapid stabilization  SAFETY -always assess for suicide (thought of hurting self) Goals of Managed Care  Coordinated and efficient care to control costs  Appropriate utilization of care resources  Increased access to preventative care  Maintenance and improvement of quality care What is Milieu Therapy?

 1-it is “a healing” environment  2-How do we use this milieu?  3-What do we accomplish in the milieu? Purpose  Promote mental health & rehabilitation o Focus on group process o Democratic o Interdisciplinary approach o Safety is paramount o Focus on basic needs first Milieu/Environment  Safety Structure  Norms Limit setting  Balance: negotiating a line between independence and dependence  Environmental modifications: changing environment to promote mental health Seclusion and Restraint  The Join Commission – has developed standards to guide efforts to reduce the use of restraints  Omnibus Reconciliation Act (1987) – put stringent limits on the use of physical and chemical restraints o Nursing homes  “staff convenience  MUST BE MEDICALLY NECESSARY  Used primarily to prevent physical injury to client, other clients, and visitors  Sometimes a quiet area is used to reduce stimulation for a client who is overwhelmed on an open unit  Sometimes used to prevent major damage to a unit or major interference with a therapeutic environment Assess the need for seclusion or restraint  Assess client needs of others  Talk to client in a quiet area  Intervene early to prevent escalation  Use least restrictive interventions principle  Never use as punishment  Document o Risk for injury o What was tried before restraint or seclusion was implemented o Client response to those intervention Continuum of least restrictive interventions  Verbal intervention  Involve in activities if possible  PRN medication  Seclusion  Medication given IM without the client’s consent (chemical restraint)  Physical restraint as last resort Use of Seclusion or Restraint  Assure adequate numbers of staff are available

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Give choice to walk to the seclusion area Give client a few seconds to decide if he or she will walk to the seclusion area If client does not adhere, each staff member grabs a limb and lowers the client to the floor (take down procedure)  Carru client to seclusion area  Apply restraints  Search client for dangerous objects  Administer IM medication if ordered and appropriate After Implementing Restraints  Consult physician or ARNP or notify as soon as practical  Nurses may implement restraint or seclusion in case of an emergency, but a physician’s order is required within an hour  Have physician or ARNP examine client within 1-3 hours and again every 12 hours  Explain reasons to client and family  Offer emotional support  Document Nursing Actions for the Client in Restraints  Observe at least every 15 minutes and document o Level of consciousness o Mental status o Vital signs o Loosen 4 point restraints one at a time every 2 hours o Provide meals (without utensils) o Offer food and fluids every 2 hours o Provide for hygiene and toileting every 2 hours o “Debrief” or discuss the episode with the client when s/he has regained control

o CHAPTER 3 – LEAGAL ISSUES Terms  Ethics: study of philosophical beliefs about what is considered right or wrong in a society  Bioethics: ethical concerns related to client care Ethical Principles  Beneficence: promoting good

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Autonomy: the right to make one’s own decisions Justice: treating others fairly and equally Fidelity: doing no wrong to the client; observance of loyalty and commitment to the client  Veracity: telling the truth Sources of Laws  Common Law  derived from judicial decisions  Statutory Law  created by federal and state legislatures  Administrative Law  developed by administrative agencies, such as the state boards of nursing Major Court Decisions Common Law:  M’Naghten rule (1843) – standard – not criminally responsible at the time of the act, due to mental illness  Wyatt V. Stickney (1972) – a right to treatment o Alabama mental health system was instructed to provide safe care (including not using patients for hospital labor) o Maintain minimal safe staffing patterns o Provide the least restrictive environment o Patients are to be cared for in a humane manner  Rogers v. Okin (1979) – right to refuse treatment o Nonviolent patients cannot be forced to take medications against their will o Patients or their guardians must give informed consent before drug treatment can begin o Nurses cannot force patients to take medications “for their own good”  Tarasoff v. The Regents of the University of California (1976) – Duty to warn of threats of harm to others o National standard of practice o However, some jurisdictions still believe disclosure of confidential information is a violation of the patient’s rights  Case: Tatiana Tarasoff – a Duty to Warn – Tarasoff Case Torts (Civil Law)  Intentional o Assault  Deliberate threat and the ability to do physical harm to another  Verbal threatening o Battery  Intentional touching of another person in a socially impermissible manner  Force used o False imprisonment  Unlawful restraint of a person’s personal liberty  Restraints or confinement o o

Defamation of character Breach of confidentiality

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Unintentional o Negligence  Failure to do or not do what a reasonable person would do under the circumstances  Duty to care, reasonable care (standard of care), breach of duty, injury caused by a breach of duty o Malpractice  Professional negligence  May be brought against healthcare providers  Claims usually arise from the nurse’s failure to prevent harm to patients and failure to maintain the standard of care  Master-servant rule: employer is responsible for the acts of the employee, as long as the employee is acting within the scope and authority of employment  Exceeds clinical boundaries  Fails to act as reasonable prudent nurse  Same standards apply to nursing assistants and support staff Admission Issues  Voluntary – Involuntary – Incapacitated  Voluntary vs. involuntary admission (harm to self or others)  Involuntary treatment o Emergency care: evaluation and emergency treatment o Short-term observation and treatment: a treatable disorder that will improve with treatment o Long-term commitment: need prolonged care, but refuse to seek help; determined by a hearing officer  Incapacitated – treatment provided to a person who does not have the legal capacity to consent to treatment Justification for Hospital Admission  Clear risk of client danger to self or others  Dangerous decompensation of long-term treatment client  Failure of community-based treatment/need for structure  Medical need of psychiatric or non-psychiatric nature Goals for Acute Hospitalization  Prevention of self-harm  Prevention of harm to others  Crisis stabilization and return to community  Initiation/modification of psychotropic medication  Brief, specific problem solving  Rapid planning for outpatient therapy Government Actions  Community Mental Health Centers Act of 1963m o De-institutionalization o Provided federal funding for community health centers in the US  Affordable Care Act (2010) o Patient centered medical homes including psychiatric care

Civil Rights of Patients  Vote Civil service  Driver’s license Purchases and contracts  Press charges Humane care  Religious freedom Social interaction  Exercise and recreation Patient’s Rights  Treatment with least restrictive environment  Confidentiality of records  HIPAA  Freedom from restraints and seclusion  Prevent a patient’s escalation and loss of control by paying attention to the therapeutic nurse-patient relationship, the therapeutic milieu, and when to provide pharmacologic management Maintaining Confidentiality  Do not share information with friends or in public areas  Guard written material taken outside of the clinical area  Always keep medical records of patients you are not directly caring for  Only share information with others who “need to know” Exceptions to Client Right of Confidentiality  When duty to wan and protect are mandated -Tarasoff  When nurse is a mandated child abuse reporter  When nurse is a mandated elder abuse reporter  State laws requiring reporting of certain communicable diseases  State laws requiring reporting of gunshot wounds  State laws that do not give nurses “privilege” re: disclosures made within the context of the nurse-clint relationship Patients Right to Give or Refuse Consent to Treatment  Give or refuse consent to treatment: does the patient have the legal capacity to give informed consent to refuse medication?  The court decides whether a person is not competent (does not have capacity), and medication can be imposed on the patient  Never hide medications in food or liquid when a patient refuses; it is forcing a patient against her or his will  Psychiatric emergency medications may be administered without consent to present the patient from harming him/herself and others  Mental Illness and the Justice System  64% of local prisoners, 56% of state prisoners, 45% of federal prisoners have mental health problems  The justice system is unable to meet the needs of the prisoners with mental illness  The justice system was not designed to treat mental illness  Large numbers of inmates pretend to have mental disorders to receive medications and be in a more comfortable or safer environment within the prison Psychiatric Advance Directives  Only 25 states have advance directives for psychiatric treatment

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Advance directives for psychiatric treatment are similar to those for medical care, but there are some challenges The Baker Act – Florida Chapter 394 of the Florida Statutes is known as, “The Baker Act” and as “ The Florida Mental Health Act” A Baker Act legal proceeding is a means of providing an individual with emergency services and temporary detention for mental health evaluation and treatment, either on a voluntary or involuntary basis

CHAPTER 5 – CULTURAL ISSUES Culture  Beliefs and values held bu individual. Groups or community used as premises for daily life and functioning (about what is good, right, and normal)  Cultures are different from race or minority status, and or ethnicity Terms  Acculturation  Enculturation  Cultural competence  Ethnocentrism Cultural Competence  Proficiency in cultural competence o Awareness o Knowledge of cultural impact on the person/community o Skills to promote effective care o Incorporates cultural competence in interactions with peers, students, patients, families, and communities o Is key to the patient’s recovery process Culture and Psychiatric Nursing  Cultural diversity includes o Age Gender o Socioeconomic status Religion o Race Ethnicity o Mental illness Physically challenging conditions Barriers to Culturally Competent Care  Miscommunication between the nurse and the patient  Lack of knowledge and sensitivity regarding cultural beliefs and practices  Patients unaware of the nurse’s cultural perspectives; therefore, misinterpreting health care recommendations from the nurse  Failure to assess the patient’s cultural perspective Cultural Etiology of Illness and Disease  Nurses’ and patients’ health care beliefs and decisions are influenced by the following 3 factors: o 1- Definition of health o 2-Perception of illness and how it occurs o 3-Cultural worldview

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What causes illness or disease? Natural causes of illness: everyone and everything in the world are interrelated; a disruption of the connection causes illness  Unnatural causes: outside forces cause illness  Scientific: specific concrete explanations of the illness i.e. micro-organisms cause infections  Which model do you think most nurses believe?  Is it important to understand that these worldviews impact culturally bound mental health issues  individuals may have a mix of primary worldviews  when with family or significant others or during stress, the primary worldview predominates Four worldviews  Analytic: values detail to time, individuality and possessions; learning it through written, hand-on, and visual resources. Value material items. (ex. American society)  Relational: spirituality and the significant of relationships and interactions between and among individuals; learning is through verbal communication (African Americans, Hispanics)  Community: community needs and concerns are more important than the individual’s needs. Learning style is quiet. Respectful communication. Meditation and reading (Asian)  Ecologic: interconnectedness exists between human beings and the earth, and individuals have a responsibility to take care of the earth. Learning style is quiet observation and contemplation (Native Americans) Culture-Bound Mental Health Issues  Combination of psychiatric and somatic symptoms that are considered to be a recognizable disease only within a specific society or culture  Recurring patterns of behavior that create disturbing experiences for individuals  May or may not fit diagnostic patterns of DSM-5  Assess symptoms with culturally competent viewpoint  Can use the cultural formulation tool (DSM-5) which assess both the patient and the nurses cultural viewpoint

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Culture bound syndrome examples

Anorexia nervosa – refusal to eat, fear of being fat, altered body image, lanugo, amenorrhea (US, South America, Europe) o Susto – unhappiness and sickness following a frightening event which caused the soul to leave the body (Latinos) o Koro – fear that the penis in men and nipples and vulva in women will disappear into the body (South and East Asia) o Postpartum depression – crying, irritability, poor concentration after giving birth (US)  Symptoms are described differently, depending on the cultural group o Malayan and Laotian may describe emotional problems as “running amok.” May include outburst of violence and aggression or homicidal behavior o Native-American nations may describe as “ghost sickness” Symptoms may include weakness, dizziness, fainting, anxiety, hallucinations, confusion, and loss of appetite resulting from the action of witches and evil forces o Ataque de nervios – uncontrollable shouting trembling, crying and dissociative experiences (Latin, Caribbean)  Therapies for culture bound syndromes o Culture specific and ethno-related o Bio-medical models usually ineffective o Need knowledge of the patient’s explanatory model of illness (what does patient think caused the illness?) o Need knowledge of the patient’s explanatory model of cure (How does patient think the illness can be cured?) o Cognitive behavioral therapy can help Ethnopharmacology  Ethnopharmacology is a related study of ethnic groups and their use of drugs  Variation in metabolism can cause differences in response to medications, based on genetically based pharmakinetic variations when metabolizing the medications  For example, Asians are very sensitive to alcohol because of a deficiency of aldehyde dehydrogenase  Cytochrome P-450 system plays a major role in the metabolizing psychotropic medications  Some cultural groups are poor metabolizers Nurse’s Role in Cultural Assessment  Basic elements of cultural assessment (table 5-6, page 54) o Communication Orientation o Nutrition Family relationships o Health beliefs Education o Spiritual or religious views Biologic or physiologic elements  Cultural preservation: the nurse’s ability to acknowledge, value, and accept the cultural beliefs of the patient  Cultural negotiation: the nurse’s ability to work within the patient’s cultural belief system o

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Cultural re-patterning: the nurse’s ability to incorporate cultural preservation and negotiation to identify patient needs, develop outcomes, and evaluate outcome plans Case Study  Fatmata is a 24 yo woman from North Africa who has been admitted to behavioral unit, due to a severe depression. She is an observant Muslim who wears a head cover and eats food that is prescribed by the Quran. She requests to attend groups that are especially for women. The nurse decides to: o Honor Fatmata’s request and plan a women’s group for problem solving Value Systems

 Explanatory Models  Cause of illness  When and why did it happen?  How distressful is it?  How long will it last?  How should it be treated?  How should others treat one who is ill? Genetics  Psychiatric Illness o Mood disorders o Schizophrenic disorders o Personality disorders o Substance abuse disorders Nurse as Cultural Translator  Facilitates ethno-relativism by translating language  Explaining health-related concepts related to client culture  Best when cultural translator closely resembles the client (is from same geographical region, social class, and gender)  Culture Bound Syndrome – an illness caused by culture CHAPTER 6 – SPIRITUALITY ISSUES Aspects of Spirituality  Forgiveness

Grief

 Peace Transcendence  Trust Discovery  Fear Meaning  Alienation Purpose  Hope Relationship  Love Gratitude Common Understanding of Spirituality  Spirituality: o Connected to a transcendent source, such as God, a higher power or a universal spirit often expressed within a religious community o Seeks to distinguish spirituality from a religious perspective emphasizes aspects of the human spirit and its relationships to other human spirits in ways that are not dependent on the notion of a higher power  Case Study  Kristen was recently hospitalized in a behavioral health unit after suicide attempt. Kristen stated she took the overdose because she felt unloved by everyone, including God. What spiritual principle will help Kristen begin to sort out the issues that led to her suicide attempt o HOPE  hope assists an individual to determine a will to live. Once there is a will to live, the patient and her therapist can explore the dynamics that occurred to reinforce Kristen’s isolation Theistic View  Spirituality in relation to a transcendent spirit  Exemplified in the creation story of the 3 large monotheistic religions (Christianity, Islam, and Judaism)  Human lives inspired by a supreme being  Gratitude for basic existence Humanistic View  People attempt to bring meaning in their lives apart from a religious community or understanding of God  Emphasis is on the human spirit, both individually and collectively  Theistic and humanistic are not mutually exclusive Clinical Understanding  Positive correlation between mental health and spiritual well-being  “Sick religiosity” negative experiences with comeone or a religious institution that may have been painful or dehumanizing  “Healthy spirituality” positive experience  Importance of hope for will to live Importance of Spiritual Care  Spiritual refers to cultural, religious, or existential concerns  DSM-5: religious or spiritual problem  NANDA: Several nursing diagnoses dedicated to spiritual care o Moral distress o Hopelessness o Religiosity o Spiritual distress

Spirituality and Mental Distress  Schizophrenia: incapacity to think in an abstract manner and to understand symbolism; thinking is concrete  Religious thoughts are often a theme in hallucinations and delusions  Diminished capacity for trust is consistent cross-culturally  Patients want their practitioners to be authentic, caring, respectful, and to speak slowly and in concrete terms Assessment and Intervention  Take a spiritual history  Support and show respect for the patient’s beliefs  Pray with the patient if the nurse is comfortable doing so and the patient wants and requests this intervention  Provide spiritual care by being kind, gentle, sensitive, and compassionate  Refer to pastoral care Assessment Tools  HOPE tool o H: source of hope, strength, comfort, meaning, peace, love, and connection o O: role...