Introduction to Behavioral Health Nursing

Michigan Procedure to Involuntary Treatment: Court Hearing KNOW THIS!

probate court judge must occur within 7 days of admit excluding Sundays and holidays patients can waive their right to a hearing or defer the hearing judge can order further treatments such as medication order lasts for 60 days- even after patient D/Ced Patients are often discharged before the hearing can take place

Team and Treatment: Multidisciplinary team

psychiatrist social workers psychiatric nurses patient care workers activity therapists (OT, PT, RT) Clinical pharmacists

Structure

rationale: 1. connects behavior to consequences 2. patient control of maladaptive behaviors 3. sense of security 4. avoids confusion and enhances self-esteem (modeling use of leisure time) Examples: 1.planning activities 2.clear time and place for activities 3. consistent consequences (+/-) 4. limit-setting

Role of Psychiatric Nurse: Promote/Maintain Health

relapse prevention/management mental and physical health manage effects of disorder and stigma

Privacy and Psychiatric Care

Greater stigma requires greater sensitivity HIPAA Duty to warn (Tarasoff)

Therapeutic Milieu

*Definition:* a *scientific* structuring of .......... to effect behavioral changes and improve the psychological health and functioning *Aim:* Provide a stable and coherent social environment that facilitates the development and implementation of an individualized treatment plan

Restraint and Seclusion: Standards of Care

-documentation of justification for using restraint: ensure physical safety of the individual or others AND Least Restrictive Alternative -authorizing Other- MD in some states APRN -Observation and Good Care constant or q15 minutes vital signs and extremity check- q2hrs hydration, nutrition, toiling- PRN -"Chemical"- Restraint -Getting the patient out of restraints

community integration

-inpatient -residential -outpatient -ACT you want to get people more integrated into the community

Aspects of "Mental" that van be disordered

-thinking -mood -self/personality -experience -relational functioning -behabior "mental" is a complex phenomenon

Distinctive Aspects of Mental Disorder

1. attacks sense of self 2. socially construction 3. often defined by threshold 4. phenomenological diagnosis 5. diagnosis poor predictor of function phenomenological diagnosis: all looking at behavior; have someone tell you their feelings (no lab values)

Types of Admission: involuntary psychiatric

1. civil commitment (retains right to refuse other treatment) 2. with consent of guardian for patients adjudicated incompetent 3. court order: often more latitude in treatment

Michigan Procedure to Involuntary Treatment: 1st Medical Certificate KNOW THIS!

24 hours to evaluate the patient evaluation must be done by a physician or licensed PhD psychologist evaluator can release patient

Types of Admission: voluntary psychiatric

AMA requires 3 day notice

Role of Psychiatric Nurse: Assessment

Bio-psycho-social Culturally sensitive

Skills Oriented Services

Club House Vocational Programs/training Day Treatment Residential Treatment

Role as a Nursing Student

Conduct assessments including MSE Develop nursing care plans with EBP interventions Practice therapeutic communication participate in clinical debriefings understand and contribute to the therapeutic milieu participate on mute-disciplinary team by reporting off to the charge nurse when leaving the unit provide teaching and education document and chart if agency allows

Gunderson's Components of Therapeutic Milieu

Containment support structure involvement validation

Mental Health Services:

Continuum care (institutional --> community-based) three points of continuum (structure/restrictiveness, skills orientation, community integration) substance abuse and dual diagnosis ACT team: assertive community team

DSM-5

Dimensionality (for example alcohol use disorder has 11 possible symptoms coded for severity: mild (presence of 2-3 symptoms) moderate (presence of 4-5 symptoms) severe (presence of 6 or more symptoms) a recent change from DSM-IV-TR (multi-axis dx)

Mental Disorder as Disability: The Americans with Disabilities Act (ADA)

Disability: substantial limitation of major life activity can be applied to chronic episodic conditions effects of prevention may be considered entitled to reasonable accommodation on job employer can ask only to the extent relevant to disclose or not is the issue for many working persons with MI

Michigan Procedure for involuntary treatment: Petition KNOW THIS!

Filled out by any person (18 or older)who has knowledge that a person is mentally ill and a danger to self or others taken to a Magistrates Offie or clerk of the courts office magistrate issues a custody order or order to transport to get the patient to an area facility for evaluation or to any locally available physician

Team and Treatment: Treatment

Group therapy psychoeducation individual counseling medication milieu therapy family support/counseling activity therapy ECT

Civil Commitment

Has a mental illness and: danger to self danger to others imminent danger of significant harm because of being unable to provide for basic needs (Gravely disabled)

Mental Illness: What Is Mental Illness? (Surgeon General's Definition)

Health conditions that are characterized by alterations in thinking, mood, or behavior associated with distress and/or impaired functioning

Disparities in mental Health: Minorities

Less access less needed services poorer quality underrepresented research

Cultural variation and psychiatric assessment

Mental Status Exam (appearance, affect, speech , thought content) history symptoms (meaning, expression, social response)

Myths: Not real diseases

Mental disorders are legitimate medical illness. there are genetic biological causes for mental disorders

Myths: "Bootstraps"

Mental illness is not caused by personal weakness nor can it be cured by personal strength, proper treatment is needed

Myths: Won't affect me

Mental illnesses are surprisingly common, they affect almost every family in America, mental illnesses do not discriminate-they can affect anyone.

Continuum of Structure leads to?

More structure -more acute symptoms -more restriction -institutionally based Skills building services tend to be more community based

Role of Psychiatric Nurse: Planning

Patients and families complex problems high co-morbidity

Support

Rationale 1. comfort and sense of security (helps them feel more in control 2. lessens anxiety 3. engagement in treatment Examples: venting empathy and enhancing self-esteem unconditional acceptance safe spaces therapeutic communication

Mental Health (Surgeon General's Definition)

The successful performance of mental function, resulting in productive activities, fulfilling relationships with other people, and the ability to adapt to change and to cope with adversity; from early childhood to late life, mental health is the springboard of thinking and communication skills, learning, emotional growth, resilience, and self esteem

Cultural variation and nursing Assessment

acceptance level and type of expressed emotion non-verbal communication expectations for privacy relationship with authority gender expression, roles, and relation family sexual behavior ritual experiences time orientation developmental milestones expectations and values: "the good life" what is valued as achievement? what defines failure?

Role of Psychiatric Nurse: Organize care

access, negotiation, integration of services

Stigma

an "attribute" that is deeply discrediting and that reduces the bearer from a whole and usual person to a tainted discounted one

DSM

atheoretical No etiology (causes): except trauma and stress related or with known medical etiology menu approach number system for diagnosis Bible of psychiatric diagnosis

culture and nursing assessment and diagnosis

culturally competent psychiatric nursing diagnosis appropriately considers relevant social, cultural, and spiritual characteristics of patient don't assume patient shares your worldview discuss patient's beliefs about health and current illness ask about religion, world view, and spirituality self-assessment is necessary recognize sociocultural stressors NANDA dx Spiritual distress

Problems in the mental health service delivery system

disparities deinstitutionalization Homelessness Incarceration

Michigan Procedure to Involuntary Treatment: 2nd medical certificate KNOW THIS!

evaluation must be done by a psychiatrist must be done within 72 hours

Psychiatric Advanced Directive (PAD)

extends patient autonomy to circumstances when patient lacks decision-making capacity (DMC) due to mental disorder Applies principle of AD used for EOL care to psychiatric treatment First used in 1980s About 25 states have PAD Statutes

deinstitutionalization

from 559,000 inpatient in 1955 to 57,151 in 1998 community mental health centers Act 1963 institutional care was supposed to be replaced by community care, but projected need was 2,000 community mental health centers fewer than 700 were created

Committed patients are still considered to have what?

have decision-making capacity

Ethical Justification for using restraint in mental health treatment

imminent danger to self or others least restrictive method other measures tried without success implemented with standard of care reasonable efforts to recuse use

Continuum of Structure

inpatient day hospital intensive outpatient outpatient residential treatment ACT Team: assertive community team as you go up the list, more structure, as you go down the list, less restrictive

Coercion must be....

justified as an exception to respect for autonomy. Otherwise, coercion violates a patient's rights

Principles of coerced care in mental health

justified by dangerousness (some outpatient based on insight/capacity) least restrictive alternative (no restriction as behavior modification) treatment (not merely custodial care)

current commitment standards...

leave a gap when a person is mentally ill and lacks ability to decide in their own best interests but is not dangerous

Myths: No treatment

most mental disorders can be efficiently treated

John is suicidal, depressed and having paranoid delusions that FBI is targeting him. He often refuses his meds. What is his primary care?

safety respond to the affect

therefore, other forms of coerced treatment, such as forced medication or restraint requires additional what?

separate legal authorization

Types of admission: voluntary medical

sometimes called informal in psych no notice required to leave AMA

Assessing Danger

standard is "imminent danger" clinically difficult statistically difficult (prediction of low-probability events)

A greater proportion of Mental Health care is paid by the government especially ------- gov

state

hospital-based psychiatric Nursing care

structure safety stabilization most admitted patients in crisis Short LOS

what do you treat with a mental illness?

the symptoms, NOT the illness symptoms are often self-reported

Aspects of Inpatient Care

therapeutic containment for safety and trust (least restrictive environment & seclusion/restraint in emergencies to prevent harm) therapeutic verbal interaction guided social interaction consistent limit setting decreased external stimuli PRN meds