Psych Exam 1: Chapters 2, 5, 6, 7, 8, 9

Veterans Administration Centers:

veterans receive federally funded inpatient or outpatient care and medication for psych/alcohol/substancde abuse -veterans struggle facing with PTSD

Alcohol and Drug Abuse Treatment:

* all the mental health settings provide treatment for alcohol and substance abuse -treatment is typically outpatient, includes medication mgmt, and 12 step programs * b/c alcohol detoxification can be life threatening, inpatient care may be required for medical mgmt. * drug rehab facilities provide inpatient care for detoxification of drugs, including opiates and chemicals and offer all levels of outpatient care.

Presupposition questions: "the miracle question":

" suppose you woke up and a miracle happened and this problem had gone away. What would be different and how would it change your life?" - can reveal a lot about what what the pt is motivated to pursue and can get to the crux of the client's most important issues.

Intensive Outpatient Programs:

(IOP's): provide structured programs to bridge the gap between inpatient and outpatient treatment for people who require more than outpatient care or who may need transition form an intensive setting * treatment includes individual and group therapy as well as psychosocial education for at least 4 hrs/week

Projective questions: The "what if" question...

* "what if" questions help ppl articulate, explore, and identify thoughts and feelings -projective questions can also help ppl imagine thoughts, feelings, and behaviors they might have in certain situations. ex: " if you had 3 wishes what would you wish for?"

Active Listening:

* Active listening includes: -observing the pt's non-verbal behavior -listening to and understanding the patient's verbal message -listening/understanding the person in the context of the social setting of his or her life -listening for "false notes"; incongruencies that are in need of further clarification -PROVIDE THE PT WITH FEEDBACK about himself/herself OF WHICH THE PT MAY NOT BE AWARE * ADVICE to experienced clinicians and students:

The Communication Process:

* Berlo's Classic Communication Model: 1) Stimulus: a stimulus can be a need for info, comfort, or advice 2) Sender: person sending the message initiates the interpersonal contact 3) Message: information sent or expressed to another -the Clearest Messages: well organized or expressed in a manner familiar to the receiver 4) Media: recall that a message can be sent through a variety of media (hearing, seeing, touch, smell) 5) Receiver: person receiving the msg, interprets the message, and responds to the sender by providing feedback * nature of feedback determines how the message was interpreted by the receiver. ^ this needs to be validated for accuracy of the message " Do you mean..?" " I notice you turning away when we talk about your going back to college. Is there a conflict there?"

Forensic Psychiatric Care:

* Incarcerated Populations: high incidence of mental illness/disorders as well as substance abuse * treatment CAN be provided within the prison population; these inmates will be separated from the general prison population * most facilities provide: -psychotherapy -group counseling -medication mgmt -assistance with transition to the community

Psychiatry's definition of "NORMAL" mental health:

* Normal Mental Health: changes over time and reflects changes * recall that we are taught to focus on areas of high functioning and strengths of the mentally ill - in these strengths, we develop and encourage -recall that those of us who are "normal" or "mentally healthy" may have several areas of dysfunction at different times of their lives. (everyone is different) * there can be no one definition of mental health that fits all ^ there are some traits that mentally healthy people share and contribute to a better quality of life.

Culture and Mental Illness:

* The DSM includes info specifically realted to culture in 3 areas: 1) discussion of cultural variation for each of the clincial disorders 2) a description of culture-bound syndromes 3) an outline designed to assist the clinician in evaluating and reporting impact of individuals's cultural context * health care providers must consider the norms and influences of culture in determining the mental health or mental illness of the individual. * throughout history, people have interpreted health or sickness according to their own cultural views. (ex: back in the day, people thought someone who was different as possessed by a demon; exorcisms would take place) * culture can dictate the types of behavior categorized as mental illness. * for example, the content of a person's delusions, hallucincations, obsessional thoughts and phobias often reflect what is important in the person's culture. *Running amok: form of mental illness seen in Southeast Asia usually among males; seen engaging in furious and indiscriminate violent behavior *Pibloktoq: an uncontrollable desire to tear off one's clothing. and expose oneself in severe winter weather.; this is a recognized disorder in Greenland, Alaska, and Arctic Regions of Canada. *anorexia nervosa: in our own society ^ is also well-known in europe, N. America, australia, etc... ^ why is this the case? Why are some disorders seen in some places and not others? 1) conditions necessary for causing a particular disorder occur in some places and not others. 2) people learn certain kinds of abnormal behavior and engage in imitation *the fact that some mental illnesses are culturally determined does not prove that all mental illnesses are so determined ^ex: schizophrenia/bipolar are found all across the world * ex of traditional helping strategy: ^ we use american mainstream therapies; "therapist" uses a metaphor in the form of a "story" to offer a social message but will not directly give advice or tell the person what to do ^ listeners are left to draw their own conclusions and make changes if they are ready to do so. *The most effective therapist: those who are eclectic in their knowledge, come from a background of working with different cultures, have a broad knowledge of coping strategies, and are flexible in their approach.

Verbal communication: Nonverbal communication:

* all words * tone and pitch, manner, pace, -culture plays a big role here :) posture, amount of eye contact, eye cast, hand gestures, sighs, fidgeting, and yawning. * Social cues: physical appearance, facial expressions, body -recall that communication is 90% nonverbal and 10% verbal * communication involves 2 radically different but interdependent kinds of symbols: 1) spoken word: which represents our public selves. -verbal assertion can be straightforward comments or skillfully can be used to distort, deny, and generally disguise true feelings. 2) nonverbal behaviors: covers a wide range of human activities, from body movements to responses to the message of others. -how we listen, use silence, and sense of touch may also convey important information about the private self that is not available from conversation alone especially when viewed from a cultural perspective.

Factors that affect the severity and progress of a mental illness:

* can be biologically or environmentally based: -

Child and Elder abuses Reporting Statutes:

* child abuse reporting statutes: differ from state to state; generally include a definition of child abuse -many states require nurses to report cases of suspected abuse -note that there is conflict between state and federal laws w respect to child abuse reporting when the health care professional discovers child abuse or neglect during the suspected abusers' ALCOHOL OR DRUG TREATMENT. * elder abuse: -RN's must report -medicare and medicaid have even stricter rules regarding reporting cases of suspected elder abuse * OLDER ADULT: adult 65 and older * dependent adults: btw. the ages of 18-64 whose physical/mental limitations restrict their ability to carry out normal activities or protect themselves. * RECALL that a person who is required to report suspected abuse, neglect, or exploitation of a disabled adult and who willfully does not do so is guilty of a misdemeanor crime. -you are also allowed to report suspicion of mental abuse or suffering

What are the 2 main principles that guide the communication process during the nurse-patient interview?

* clarity: ensures that the meaning of the msg is accurately understood by both the parties " as the result of joint and sustained effort of all parties concerned" * continuity: promotes connections among ideas and the feelings events or themes conveyed in those ideas.

An intro to the importance of Therap Communication:

* developing the skills to determine levels of pain in the post-op client or to understand without hearing the words of the needs of the intubated voice-less patient in the intensive care unit is essential to quality nursing care! :) you will say the wrong thing in practice probably many times.. it cannot be prevented

Exceptions to the Rule!!!

* duty to warn: " duty to warn and protect 3rd parties" -ex: psychologist verbally and written notice of her patient to harm a particular student ^ he later killed her even after police believed he was rational * the duty to protect the victim from danger arises when the therapist determines or persuant to professional standards should have determined that the patient presented a serious danger to another. * DUTY TO PROTECT: broadening of the DUTY TO WARN * DUTY TO WARN INCLUDES THE FOLLOWING: -assessing and predicting the patient danger of violence toward another -identifying the specific individuals being threatened -taking appropriate action to protect the identified victims. * nursing implications: -assume that the duty to warn 3rd parties will be applied to advanced practice psych mental health nurses in private practice who engage in individual therapy * failure to inform staff about potential harm to another client is a failure and substandard of nursing care!!! *BREACH of patient-nurse confidentiality should not pose ethical or legal dilemmas for nurses in these situations, because a team approach to the delivery of psych care presumes communication of pertinent info to other staff members to develop a treatment plan that will be in the best interest of the patient.

Lethal and Ethical Concepts:

* ethics: study of philosophical beliefs about what is considered right or wrong in a society * bioethics: is a more specific term that refers to the ethical QUESTIONS that arise in health care. * The 5 Principles of Bioethics: 1) beneficence: duty/act that promotes benefit or good to others ex: spending extra time to help calm an extremely anxious patient is a beneficent act 2) Autonomy: respecting the rights of others to make their own decisions ex: acknowledging the patient's right to refuse medication in an example of promoting autonomy 3) Justice: the duty to distribute resources or care equally, regardless of personal attributes. FAIRNESS ex: ICU nurse must devote equal time to both patient who has just attempted suicide and a patient who has just suffered an aneurysm. 4) Fidelity: NON-MALEFICENCE; maintaining LOYALTY and commitment to your patient and doing no wrong to the patient. ex: maintaining nursing skill through nursing skill through nursing education demonstrates fidelity to patient care. 5) Veracity: One's duty to communicate truthfully ex: describing the purpose and side effects of psychotropic medications in a truthful and non-misleading way is an example of veracity. * the book advises that we follow the law...in the event that an ethical dilemma conflicts with the law..

Affordable Care Act (Obamacare)

* helped insure many people * some changes in insurance: -insurance can no longer deny coverage r/t pre-existing conditions or for re-sending or taking away insurance for health/mental health related reasons -expansion of coverage to young adults up to the age of 26 under their parent's insurance - provision for people over 65 on medicare; 50% discount on brand name drugs who reach the medicare "DOUGHNUT HOLE" -provides small business tax credits -provides affordable coverage to millions of americans who aren't able to afford care -people with existing healthcare coverage are able to keep or choose their doctors

Paying for Mental Illness:

* limits in health insurance are problematic in terms of coverage for mental illness -most health insurance is employer based and mental illness can oftentimes lead to job loss ^ therefore, many w mental illness have no coverage - note that state systems exist in part as a safety net for the limits in health insurance * note that most private insurers have enacted coverage limits that are more restrictive for treatment of mental illness than other illnesses * note that coverage varies by state! -some states provide coverage for all mental illness -other states limit the coverage to specific biologically based illnesses * IN OHIO: the list includes -schizophrenia -schizoaffective disorder -major depressive disorder -bipolar disorder -paranoia -some other psychotic behaviors -OCD -panic disorder

Hildegard Peplau

* mother of psychiatric nursing -had a passion for clarifying and developing the art and science of professional nursing practice and believed that a scientific approach was essential to the practice of psychiatric nursing. -she also introduced the concept of advanced nursing practice and promoted professional standards and regulation through credentialing * recall that psychiatry was 1 of the 1st medical specialties to extensively use randomized controlled trials -1 of the founding principles of clinical psychology in the 1950s was that practice should be based on experimental comparisons of treatment methods. * w/o scientific evidence for practice, much of nursing care has been based on tradition, personal experience, unsystemic trial and error the the earlier experiences of other nurses and health-care professions.

*Outpatient Care Settings:

* note that Primary Care Providers are usually the 1st choice of care for most people when they are ill * many people associate mental illness with physical illness since many times, mental illness is often manifested as physical illness. ^ also, people tend to feel more comfortable in an environment they are more familiar with. * the downside to this: a 15-minute appointment is usually inadequate for a mental and physical assessment -additionally, PCP's generally have limited training in psychiatry; may lack expertise in the Dx and treatment of psychiatric disorders. -additionally, this may be the only source people use for receiving mental health care; a PCP may refer people into a specialty mental health care.

Mental Health Laws:

* note that laws have been enacted to regulate the care and treatment of the mentally ill - these laws vary from state to state -many of these laws have undergone change form 1963 -this shift has brought an emphasis and more widespread use of psychotropic drugs in the treatment of mental illness ^ this has enabled many people to integrate more readily into a larger community as well as an increasing awareness to provide the mentally ill with equal rights/care * 2010 Health Insurance Exchanges program: -requires that each state offers mental health care and substance abuse services equal to other medical services.

Self-Help Options:

* obtaining sufficient sleep, meditating, eating right, exercising, abstaining from smoking, and limiting the use of alcohol are healthy responses to a variety of illnesses such as DM and hypertension. * lifestyle choices play a big role in self-help ^ profound influence on life. * we must accept the notion that psychiatric disorders are usually a combo of biochemical interactions, genetics, and environment, then it stands to reason that by providing a healthy living situation, we are likely to fare better. * ex: if a person has anxiety; first good step is to perhaps take up yoga as a form of exercise :) ^ engage in community self-help groups * consumers: people who use mental health services and their family members have successfully united to shape the delivery of mental health care. * recovery: self-mgmt of mental illness ^ NAMI encourages this (national alliance of mental illness)

Prevalence Rate:

* proportion of a pop with a mental disorder at a given time * about 1/2 of americans will meet the criteria of a DSM disorder at some point in their life w/ the 1st in onset of childhood or adolescence * it is important to note that many ppl experience MORE than 1 mental disorder at a time (ex: someone may be diagnosed with depression and may also be experiencing anxiety) ^ this is referred to as a DUAL DIAGNOSES or COEXISTING DISORDERS

Maintaining Patient Confidentiality:

* recall that the code clarifies that the duty to remain absolute patient confidentiality is not so -in some situations disclosure may be mandated to protect the patient, other ppl, or public health * discussing patient info with other staff members to determine best treatment is NOT A BREACH IN CONFIDENTIALITY

Rights regarding Restraint and Seclusion

* recall that the least restrictive means of restraint for the shortest duration is always the general rule 1st line interventions: verbal intervention; enlisting the cooperation of patients -meds are considered if verbal intervention fails -chemical interventions are considered less restrictive than mechanical ^ have greater effect on patients ability to relate to the environment * psychopharmacology is considered an effective helpful alternative to physical restraints * BEHAVIORAL RESTRAINT AND SECLUSION ARE AUTHORIZED AS AN INTERVENTION UNDER THE FOLLOWING CIRCUMSTANCES: 1) When the particular behavior is physically harmful to the patient or a 3rd party 2) When alternative or less restrictive measures are insufficient in protecting the patient or others from farm 3) when a decrease in sensory over-stimulation (seclusion only) is needed 4) when the patient anticipates that a controlled environment would be helpful and requests seclusion * USE OF SECLUSION AND RESTRAINT IS PERMITTED ONLY UNDER THE FOLLOWING CIRCUMSTANCES: 1) on the written order of a physician 2) When orders are confined to a specific time-limited periods (2-4 hrs) 3) when the patients condition is reviewed and documented regularly (every 15 mins) 4) when the original order is extended after review and reauthorization (every 24 hrs) and specifies the type of restraint * recall that when a pt is in restraints they must be protected from all sources of harm * note that the behavior leading to restraint/seclusion MUST BE DOCUMENTED -time pt placed and removed from restraint must also be included -pt in restraint must be assessed at reg and freq. intervals (every 15-30 minutes) for physical needs (food, hydration, toileting), safety, and comfort ^ these observations must also be documented (every 15-30 minutes) * PATIENT MUST BE REMOVED FROM RESTRAINTS WHEN SAFER AND QUIETER BEHAVIOR IS OBSERVED -no negative effect associated with the reduced use of restraints and seclusion -^ alternative methods have been successful :)

Background:

* recall there is a separate care system for those who are uninsured; has its roots in asylums that were created in most existing states before the civil war ^ these asylums were created with good "intentions" to provide optimistic and positive care ^ provided that states were holding responsibility to care for the "insane" *1950's: 2 options for psychiatric care 1) private psychiatrist's office 2) mental hospital ^ at this time there were about 550,000 patient's in state hospitals ^ majority were patients with disabling conditions who had become "stuck" in asylums * with time, the number of psych patients decreased and facilities for geriatric patient's became more available as well as insurance that became more accommodating *1999 supreme court ruled keeping patient's in psych facilities was "unjustified isolation"; ppl w disabilities have the right to live in the community * now the number of psych hospitals has been reduced overall * pharmacological breakthroughs and ability of general practitioners to administer anti-psychotic meds to treat psychosis, depression, anxiety, and other disorders; this caused an overall increase in hospital discharges. * current system of psychiatric care: -includes inpatient and outpatinet settings -decisions for level of care tend to be based on the condition being treated and the acuteness of the problem -level of care depends on the severity of the condition and acuteness of the problem -othe factors may also influence^; such as concurrent psychiatric abuse, medical problems, acceptance of treatment, social supports, and disease chronicity or potential for relapse.

Competency

* related to the capacity to understand the consequences of one's decisions * if pt is found incompetent, pt will be appointed a legal guardian or representative who will be legally responsible for giving/refusing consent - note that guardians are usually chosen among family members ^ the patients wishes are always considered when choosing a guardian * order of selection for a guardian among family members: 1) spouse 2) adult children or grandchildren 3) parents 4) adult bros and sisters 5) nieces and nephews * in the event that no one in the family wants to be a guardian: -court can appoint a court-approved social worker

Discharge from the Hospital:

* release depends on the pt's admission status! *informal/voluntary admission have right to request/receive release ^ recall some states provide conditional release of voluntary patients, enabling the treating physician to order continued treatment or outpatient basis if their clinical needs warrant further care post-discharge a) Conditional Release: -requires outpatient treatment for a specified period to determine the pt's adherence to their med protocols, ability to meet their basic needs, reintegrate into community -can only be committed through usual methods for involuntary hospitalization * involuntarily hospitalized pt who is conditionally releases: -MAY BE re-institutionalized while the commitment is still in effect w/o recommencement of formal admission procedures... b) Unconditional release: DISCHARGE; termination of pt-institution relationship -may be court or administratively ordered c) Release against Medical Advice (AMA) : treatment seems beneficial but there is no compelling reason (danger to self or others) to seek involuntary continuance of stay ^ pt may be released AMA

Intro:

* remember that a fundamental goal of psych care is to strike a balance between the rights of the individual patient and the rights of the society at large.

Ethical Dilemma:

* results when there is a conflict between 2 or more courses of action, each carrying with them favorable /unfavorable consequences. - how to respond to these dllemmas: * there are more ethical dilemmas in psych care (favorable and unfavorable consequences conflict with many decisions) ^ decision-making process is more difficult -whenever ones's value system is challenged, increased stress results... ^ sounds like psych may not be the field for me after all..

The use of Silence :)

* silence: not the absence of communication; it is a specific channel for transmitting and receiving messages -the practitioner needs to understand that silence is a significant menas of influencing and being influenced by others and, if used judiciously, CAN BE A POWERFUL LISTENING RESPONSE * pt may be reluctant to speak! -the nurse is a stranger, they may be self-conscious/embarrassed or shy * too much silence is also not good...it can be frightening to the patient Icy silence= anger among the african american community: silence may relate to anger, insulted feelings, or acknowledgement of a nurse's lack of cultural sensitivity * silence; offers opportunity to THINK, contemplate, weight alternatives, formulate ideas, and gain perspective on the matter under discussion * nurse should allow the pt to break the silence sometimes! * REMEMBER that PROLONGED/FREQUENT silence by the nurse may hinder the interview! -pt may not be sure if their messages were well-understood!!!

More nonverbal communication

* some nonverbal forms of comm are across all cultures such as facial expression -others are different such as "personal space" * content: verbal message *process: nonverbal behavior ex: actions speak louder than words; actions being the process and the words being the content * "healthy" message: one in which the content and process are congruent and straightforward ^ contradictions or incongruencies between the process and content are concerning ***DOUBLE MESSAGE: aka "MIXED MESSAGE" -how should the nurse RESPOND to a mixed message? ^ REFLECT AND VALIDATE THE PATIENT'S FEELINGS!!! ***DOUBLE-BIND MESSAGES: these messages are sent to create meaning BUT can also be used DEFENSIVELY to hide what is ACTUALLY OCCURRING, CREATE CONFUSION, AND ATTACK RELATEDNESS -a double-bind message is a mix of content and process ( what is said and what is transmitted nonverbally) * BEST EXAMPLE OF DOUBLE-BIND MESSAGE: -handicap mom -teenage daughter -mom says IT'S OKAY IF YOU GO OUT BC I CAN ALWAYS CALL 911 ^ this makes the daughter feel selfish is she goes out - if the daughter stays MOM WILL SAY " I TOLD YOU IT WAS OKAY TO GO OUT!" ^ EITHER WAY, THE DAUGHTER CANNOT WIN!!

Determination of a Standard of Care:

* standards for psych care differ markedly from minimal state requirements bc the primary purposes for setting these 2 types of standards are different -professional association's primary focus is to elevate the practice of its members by setting standards of excellence nurses must participate in continuing education courses to stay current with existing standards of care

Myths and Misconceptions:

* there is no obvious consistent line bte mental illness and mental health; in fact, all human behavior lies somewhere along a continuum of mental health and mental illness

TORT LAW APPLIED TO PSYCHIATRIC SETTINGS:

* tort: civil wrong for which money damages may be collected by the injured party (plaintiff) from the wrongdoer (defendent) *bullying: may become a recognized form of violence in our society * bullying may be encountered from nursing supervisors =, peers, patients, and even family members of patients. ^ root of this controlling type of behavior: -anxiety, stress, fear, guilt felt by bully * in psych, when RN encounters threatening and violent behavior from the patient, the use of restraint/seclusion may be required until patient demonstrates quieter and safer behavior

Admission to the Hospital:

1) medical justification for admission must exist 2) well-defined psych problem must be est. based on the current illness classifications of in the current: Diagnostic and Statistical Manual of Mental Disorders (DSM) authored by the American psych Association 3) illness should be one that causes an immediate crisis that requires hospitalization and has no other less restrictive alternatives (inadequate/unavailable) 4) should be reasonable expectation that the hospitalization and treatment will improve the existing problems ! (hospitalization should have a goal in mind to help the pt!) * Olmstead v. L.C (1999): supreme court ruled; states are required to place pts w/ mental illness in less restrictive community settings rather than institutions WHEN the treatment PROFESSION has determined that a community setting is appropriate and the pt is not opposed to the decision of transferring from an institution to a community facility.

***CLARIFYING TECHNIQUES: THESE ARE SO IMPORTANT

* use of clarifying techniques: -helps both participants identify major differences in their frame of reference -this gives the 1) Paraphrasing: can be done by restating -it is another way of confirming interpretation before the interview proceeds " i'm not sure i understand.." "in other words you seem to be saying.." ^ the nurse helps form a more clear perception of what may be a bewildering mass of details " was i correct in saying.." patient may confirm or deny * THE PATIENT becomes very aware that the interviewer is actively involved in the search for understanding 2) Restating: -in restating the nurse mirrors the patient's OVERT and COVERT messages -this technique may be used to echo feeling as well as content!!! ***RESTATING differs from paraphrasing in that it involves repeating the same key words the patient has just spoken " Your life has no meaning.." ? ^^^ don' use this too frequently!!! parroting or mimicking can become very annoying -it can be seen as condescending or used to poke fun of.. - this can become a barrier * a good way to prevent this is by combining restatements with direct questions: -"what does your life lack?" -" what kind of meaning is missing?" -"describe one day in your life that appears empty to you?" 3) reflecting: means of assisting people to better understand their own thoughts and feelings -may take the form of a question or a simple statement that conveys the nurse's observations of pt when sensitive issues are being discussed. " you sound as if you have had many disappointments.." * sharing observations: shows acceptance; nurse helps make the pt aware of inner feelings and encourages the pt to own them " you look sad."... pt may then spontaneously tell you how you're feeling * use of a question in response to the patient's question is another reflective technique: patient: do you think i need to be hospitalized ? nurse: what do you think jane? pt: idk that's why im asking you nurse: ill share with you at the end of this session. However, you've probably thought about hospitalization and have some feelings about it. I wonder what they are.. 4) exploring: this technique enables the nurse to examine important ideas, experiences, or relationships more fully * ex: pt tells the nurse he does not have a good relationship w/ wife: nurse: "tell more more about your relationship with your wife" pt: " give me an example of how you and your wife don't get along" * asking for an example is a good way of clarifying a vague statement or even a very generic statement ex: pt: " no one likes me.." nurse: give me an example of one person who does not like you."

Nursing Dx:

* used to diagnose a pysch disorder * a well-defined psych disorder provides the framework for identifying appropriate nursing interventions for dealing with the phenomena a pt with a mental health disorder is experiencing (hallucinations, self-esteem issues, imparied ability to function)

Voluntary Admission:

* usually sought by the pt or guardian *must be admitted via application * have the right to obtain and demand release * many states require that a pt submit a written release notice to staff who will re-evaluate pt condition for possible involuntary status according to criteria established by state law ^SCARY

Psychiatric Rehabilitation:

*Psychiatric Rehabilitation: a social model that emphasizes and supports recovery and integration into society rather than a medical model of dysfunction. -note that serious disorders can result in isolation, poverty, and regression. * these services focus on the development of social skills, ability to access resources, and acquisition of optimal social, working, living, and learning environments.

Mental Health Parity Act: (1996) Mental Health Equitable Treatment Act:

*requires that insurers provide mental health coverage benefits at the same level provided for medical/surgical coverage * * a method used by many states use to determine coverage is by making the distinction of whether the problem is a biologically based mental illness (mental illness caused by a neurotransmittor dysfunction/abnormal brain structure/genetic factors/biological causes)

When you suspect Negligence:

-as a nurse you have a legal duty to report a suspicion of negligence by another practicing nurse to a patient -it is important to document the evidence clearly and accurately before making serious accusations against a peer - if you question a physicians orders or actions or those of a fellow nurse, it is wise to communicate these concerns directly to the person involved!!! -THEN if the behavior continues you must report it to your supervisor

Table 8-1: Nonverbal Behaviors * complete this..

-body behaviors: posture, body movements, gestures, and gait ex: -facial expressions: frowns, smiles, grimaces, raised eyebrows, pursed lips, licking of lips, tongue movements -eye cast: angry, suspicious, accusatory -voice-related behaviors: tone, pitch, level, intensity, inflection, stuttering, pauses, silences, fluency - observable autonomic physiologic responses: increase in respirations, diaphresis, pupil dilation, blushing, paleness -personal appearance: grooming, dress, hygiene -physical characteristics: height, weight, physique, complexion

non-therap comm

-excessive questions: -especially excessive close-ended questions -casts role of nurse in the interrogator, raises the demand for info w/o respect for pt willingness or readiness to respond. -always best to follow the pts lead. knowing a lot of facts about a person is not the goal you can have numerous facts but miss the person entirely

What are the goals of the nurse in the mental health setting to the help the pt?

-feel understood and comfortable -identify and explore problems relating to others -discover healthy ways of meeting emotional needs -experience satisfying interpersonal relationships * nurse should help the pt feel safe and hopeful that POSITIVE CHANGE IS POSSIBLE ***THIS IS THE GOAL IN THERAP COMMUNICATION: nurse can work with the pt to increase critical thinking skills, learn new coping behaviors, and experience more appropriate and satisfying ways of relating to others. ^ in order to do this, nurses must be very aware of their own interpersonal methods., ELIMINATING OBSTRUCTIVE NONTHERP techniques and developing additional responses that maximize nurse-pt interaction TO INCREASE THERAP TECHNIQUES

What are the mandates of the recovery model?

1) mental health care should be consumer and family-driven 2) care must focus on increasing consumer's ability to be successful in coping with life's challenges, facilitating recovery, and building resilience, NOT just "managing" the symptoms. 3) an individualized plan of care is to be at the core of consumer-CENTERED RECOVERY, recovery oriented services that allow consumers to realize improved mental health and quality of life. 4) consumers must be partners in decision-making in all aspects of care.

Involuntary Admission:

-made without the patient's consent! -done when pt is a danger to themselves, others, cannot take care of themselves. * requires that the patient RETAIN freedom from unreasonable body restraints, as well as right to informed consent, right to refuse meds * including psychotropic or antipsychotic meds. *The 3 different commitment procedures: 1) judicial determination: 2) administrative determination: 3) agency determination: * additionally, a number of physicians must certify that a person's mental health status justifies detention and treatment *further categorizations: a) Emergency Hospitalization: -may be authorized by law to prevent harm to self and other for 1-10 days on average b) observational or temporary hospitalization: -longer duration that emergency hospitalization -primary purpose: observation, diagnosis, treatment -certification by 2 or more physicians, judicial review, administrative review is often required for involuntary admission c) long term or formal hospitalization: -primary purpose: extended care/treatment of the mentally ill -are committed through medical certification, judicial or administrative action. -judicial hearing is not always required BUT pt is provided the opportunity for judicial review after commitment procedures. *this type of involuntary hosp. usually lasts 60-180 days BUT may be or an indeterminate period. d) Involuntary outpatient commitment: -preventative measure -allows court order before onset of psych crisis that would thus result in an inpatient commitment * the order for involuntary outpatient commitment is usually tied to receipt of good, services, provided by social welfare agencies including disability benefits/housing. ^ in order to access these goods/services the pt is mandated to participate in treatment and may face inpatient admission is he/she fails to participate in treatment. *Forced Treatment: raises ethical dilemmas regarding autonomy versus paternalism, privacy rights, duty to protect, right to treatment, HAS been challenged on constitutional grounds.

Some principles important to active listening:

-the answer is always inside the patient -objective truth is never as simple as it seems -everything you hear is modified by the patient's filters -everything you hear is modified by your own filters -it is okay to feel confused and uncertain -listen to yourself too.. * recall that active listening helps strengthen the patient's ability to use critical thinking in order to solve problems. * giving the patient undivided attention: nurse communicates that the pt is not alone thus enhancing self-esteem and courage -voicing thoughts: often helps the pt clarify thinking, link ideas, and tentatively decide what should be done and how best to do it. * active listening: an art that develops with practice over time

Multistep process of integrating EBP into clinical practice; 5 A's

1) Ask: ask a question; identify a problem or need for change for a specific patient or situation. 2) Acquire: literature; search the literature for scientific studies and articles that address the issues of concern 3) Appraise: the literature and evaluate and synthesize the research evidence regarding it's validity, relevance, and applicability using criteria of scientific merit. 4) Apply: the evidence! Choose interventions that are based on the best available evidence with the understanding of the patient's preference and needs. 5) Assess: the performance; evaluate the outcomes using clearly define criteria and reports and document results!

What are some factors that affect communication?

1) Personal Factors: -emotional factors (mood, response to stress, personal bias, relationship understandings) -social factors (previous experience, cultural differences, language differences, lifestyle differences) -cognitive factors: problem-solving ability, knowledge level, and language use) 2) Environmental Factors: -physical factors: background noise, lack of privacy, uncomfortable accommodations -societal determinants: sociopolitical, historical, economic factors, presence of others, expectations of others 3) Relationship Factors: are the participants equal or unequal? -friends or colleagues tend to be "SYMMETRICAL" relationship ( ex: - perceived difference in status or power= complementary relationship ^(ex: difference in status, social stat, developmental differences, gender/educational differences can all be influential on the communication process. * In US capitalism "intimately" ties systems of privilege with systems of oppression through economic control * power groups retain unequal control through stereotypes, prejudice, and bias. -stigma plays a big part in keeping relationship factors unbalanced.

Patient's rights under the law:

1) Right to Treatment: *treatment must meet the following criteria: -humane environment -staff must be qualified/sufficient to provide adequate treatment -individualized plan of care 2) Right to refuse Treatment: -a pt may withdraw consent at any time * note that the mentally ill pt right to refuse treatment with their own psychotropic drugs has been debated in courts! do they have the competence to make these decisions given their altered mental status? * the notion of refusing treatment becomes especially important if we consider medication to be a "chemical restraint" ^ IF IT IS, lack of pt liberty is equal to involuntary commitment ^ in this case, the NON-INSTITUTIONALIZED, competent, mentally ill pt has the right to determine whether they should be involuntarily committed or to be medicated. * a lot of gray area here...^^^ 3) Right to informed consent: based on person's right to self-determination -pt's also have the right to voice complaints/recommend changes in policies or services offered by the facility w/o fear of punishment or reprisal * for consent to be effectively legal it must be informed Patient's must be informed: 1) nature of their problem or condition 2) nature and purpose of a proposed treatment 3) risks and benefits of that treatment 4) alternative treatment options available 5) probability that proposed treatment will be successful 6) risks of not consenting to treatment * important for RN to know that presence of psychotic thinking does not mean that the pt is incompetent or incapable of understanding

Challenges in navigating/accessing care system:

1) do not have much frame of referece 2)^ we are unlikely to benefit from the experience of others bc having a psych illness is often hidden as a result of embarrassment or concern over the stigma 3) mental illness or disorders w a psychotic component may disorganize thoughts and impede a person's thoughts and impede their ability to recognize their need for care ex: depression causes of feelings of apathy, hopelessness, and anergia (lack of energy) 4) mental health issues are also confused as other issues ex: anxiety manifests itself w symptoms of racing heartbeart, sweaty palms, dizziness which can be confused as issues of a cardiac problem * recall that diagnosing psychiatric illness is largely base don symptoms and not on objective measurements, such as EKg * Least Restrictive Environment: setting that provides the necessary care while allowing greatest personal freedom

Psychobiological Disorder:

1) schizophrenia 2) bipolar disorder 3) major depression 4) obsessive compulsive and panic disorders 5) posttraumatic stress disorder 6) autism * more severe and disabling mental disorders: 1) anorexia nervosa 2) attention deficit and hyperactivity disorder * recall that many of the most prevalent and disabling mental disorders have been found to have strong biological influences. ^ these can be looked at as diseases. * be cautious of the terms "mental disorders" and "physical disorder" ^ there is much physical and mental and mental in physical

What are some useful tools when communicating with patients?

1) silence 2) active listening 3) clarifying techniques

Partial Hospitalization Programs:

Function as an intermediate step between outpatient and inpatient care * THEY ARE THE MOST INTENSIVE OF OUTPATIENT CARE AND TEND TO BE 4-8 hrs per day for up to 5 days/week *structured programs are provided with nursing and medical supervision, intervention, and treatment * patient's whose symptoms are under control spend some time at the facility during the day, and return to their homes at night where they can receive family support at home -coping strategies are also learned during the program and can be applied and practiced in the outside world and then later explored/discussed. - a multidisciplinary team facilitates the group therapy, individual therapy and other therapies * PATIENT'S WHO ARE ADMITTED TO PHP'S ARE CLOSELY MONITORED IN CASE OF NEED FOR READMISSION TO INPATIENT CARE.

Inpatient Care Settings:

Inpatient Care Settings: -has changed significantly in the past 25 yrs! -decline has been caused by improvements, tougher limitations of covered days by insurance plans, and alternatives to inpatient hospitalization such as PHP's (partial hospitalization programs and residential facilities) -provide 24-hr nursing care in a safe and structured setting for people in need of a restrictive environment -this type of setting is necessary/ideal for those who are in need of protection from suicidal ideation, aggressive impulses, medication adjustment and monitoring, crisis stabilization, substance abuse detoxification, and behavior modification. -referrals may come from a PCP or mental health provider, agencies, another hospital unit, emergency facilities, or nursing homes. -hospital admissions are made under the services of a psychiatrist although the PCP also has admitting privileges. -patients may also be admitted voluntarily or involuntarily -units may be locked/unlocked *locked units: provide privacy and prevent elopment or leaving before being discharged (away without leave) *psychiatric intensive care units: provide better monitoring of those who display an increased risk for danger to self or others. *therapeutic milieu: essential to successful inpatient treatment -refers to an environment in which holistic treatment occurs and includes all members of the treatment team, positive physical setting, interactions between those who are hospitalized, activities that promote recovery. inpatient care provides a structured environment in which patients perform all of their ADL's; school attendance is required for those under the age of 18 inpatient rooms actually resemble hotel rooms -showers may be in individual rooms or dorm style w/ 1 or 2 per hallway -rooms are private, semi-private, occasionally wards. -units may be male/female/co-ed *have safety features: * note that hanging is the most common method of inpatient suicide -closet rods, hooks, towel bars, and shower rods are made to break if someone tries to hang themself on it. .. -locked windows, platform beds, furniture with rounded edges to prevent intentional injury -furniture are usually heavy and durable so that it cannot be thrown/dismantled/used as a weapon * in psychiatric care, an initial MEDICAL assessment is still completed to rule out or consider re-occurring/comorbid conditions *electroconvulsive therapy: ??? still done??? -ordered for patients unresponsive to antidepressants. GROUP THERAPY: important facet of inpatient care the length of stay depends on severity of mental illness; however, avg length of stay nationwide is 8 days -for substance abuse the average length of stay is 4.8 days * discharge planning always begins on the day of admission effective case management and collaboration also reduce recidivism; at discharge patients should be stabilized... ^ sometimes this includes a private residence, shelter, halfway house, or group home.. *crisis care: provided in emergency dept of general hospitals or in community-based crisis intervention centers. may be initiated by an individual, friends, family, health care provider, or law enforcement personnel - some pts are involuntarily committed.. *psychiatric emergencies: 1) suicidal/homicidal ideation 2) acute psychosis 3) behavioral responses to drugs ^ these types of stays tend to be short; less than 24 hrs ^ then the pt is usually discharged home, inpatient care, or transferred to another community facility such as a shelter *Residential Treatment Programs: -structured short or long term living environments in which individuals are provided with varying levels of supervision and support.. ^ here the residents are encouraged to achieve max independence; access community support as opposed to hospitalization

WHAT NURSING THEORIST FOUNDED "ART OF COMMUNICATION"?

Pepleau!

Psych RN's:

Psych RN's are expected to have the following extra skill set: -biology -pyschology -social sciences * note that nurses specializing in this area will be in increasing demand as the population ages.. * Geropsychiatric Nursing: this will become more common * in the near future: advanced practice psychiatric nurses may collaborate more with primary health care providers or may even have their own independent practices to fill the gap in existing community services.

Role of Nurses in Outpatient Care Settings:

RN's who work in outpatient settings provide nursing care for ppl w/: -mental illness -alcoholism -substance abuse problems -mental retardation -developmental disabilities -also care for their families and caretakers *Community Mental Health Nurses: work to develop and implement a plan of care along with the multidisciplinary treatment team ^ the RN may choose to be certified in psychiatric mental helath nursing or hold advanced practice degrees *community mental health nurses MUST be very knowledgeable about community resources such as shelters for abused women, food banks for ppl in severe financial limitations, and agencies that provide employment options for people with mental illness. -the RN also assesses the patient's living arrangements - an important concept for community mental health nurses is viewing the entire community as a patient!!! ^ having this POV promotes community interventions such as conducting stress reduction classes and grief support groups, etc.. ***MUCH MORE COMMUNITY BASED

Resiliency:

Resiliency: characteristic of mental health that is increasingly being promoted -ability to recover from/adjust easily to misfortune and change -closely associated with process of adapting -helps people face tragedy, loss, trauma, and severe stress * resiliency is a trait expressed in many people and can be developed in almost anyone * being resilient does not mean someone is unaffected by stressors * rather than falling victim to negative emotions, resilient people recognize feelings, and more readily deal with them; learn from the experience given time...

recovery model:

SOCIAL model of disability -focus shifts from illness and disease to an emphasis on REHAB AND RECOVERY recall that the recovery model originated from the 12-step program of alcoholic anonymous concept of recovery: refers primarily to managing symptoms, reducing psychosocial disability, and improving role performance. remember that recovering from a mental illness is viewed as a personal journey of healing.

Patient Privilege and HIV status:

SOME states by law require that the spouse of an HIV positive patient must be informed

Defamation of Character:

Slander: spoken Libel: written

Duty to Intervene and Duty to Report:

a nurse who follows an order that is known to be incorrect or that the nurse believes will harm the patient is responsible for the harm that results to the patient. * abandonment: may arise when a nurse does not leave a patient safely reassigned to another health professional before discontinuing treatment * abandonment issues arise when accurate, timely, and thorough reporting has not occurred or when follow-through of patient care on which the patient is relying has not occurred.

Rights After Death:

a person's reputation can be damaged even after death -it is important not to share info after a person's death that couldn't be shared before death -THE DEAD MAN'S STATUE protects confidential information about people when they are not alive to speak for themselves * theory behind privileged communications: patients won't be comfortable or willing to disclose personal info about themselves if they fear that nurses will repeat their confidential conversations even after death * EXCEPTIONS IN SOME STATES: -recall that in some states in which legal privilege of confidentiality has not been legislated for nurses, you must respond to a courts inquiries regarding the patients disclosures even if this info implicates the patient in a crime ^ IN THESE STATES, THE CONFIDENTIALITY OF COMMUNICATIONS CANNOT BE GUARANTEED. * if a duty to report exists, YOU MAY BE REQUIRED TO DIVULGE PRIVATE INFORMATION SHARED BY THE PATIENT

Mental Health vs. Mental Illness:

a) Mental health: 1) happiness; can see in objects, people, and activities he possibilities for meeting his or her needs 2) control over behavior: can recognize and act on cues to existing limits -respond to rules, routines and customs 3) appraisal of reality: accurate picture of what is happening around the individual -good sense of consequences 4) effectiveness in work: -can do well in tasks attempted -when meeting mild failure, persists until determines whether he or she can do the job 5) healthy self-concept: -sees self as approaching individual ideals, as capable of meeting demands -reasonable degree of self-confidence that helps in being resourceful under stress. 6) satisfying relationships: experiences satisfaction and stability in relationships -socially integrated and can rely on social supports 7) effective coping strategies: uses stress reduction strategies that address the problem, issue, threat (problem solving, cognitive restructuring) -uses coping strategies in a healthy way that does not cause harm to self or others b) Signs of Mental Illness: 1) major depressive episode 2) Control Disorder; undersocialized and aggressive 3) Schizophrenic and Other Disorders 4) Adjustment Disorder With Work (or Academic) Inhibition 5) Dependent Personality Disorder: -passivle allows others to assume responsibility for major areas of life because of inability to function independently -lacks self-confidence 6) Borderline Personality Disorder 7) Substance Dependencies: repeatedly self-administers substances despite significant substance-related problems

Specialty Treatment Settings:

a) pediatric psychiatric care: same as adult care * family is more important in pedi care -hospitalized children must still attend school for several hours a day b) geriatric psychiatric care: these settings take into account the aging effects on the geriatric population -physical illness/loss of independence can be strong participants in development of depression/anxiety -dementia is a common issue among the geriatric population -treatment is aimed at careful evaluation of the interaction of mind and body and provision of care that optimizes strengths, promotes independence, and focuses on safety (everyone is a fall risk essentially....) * special attention to optimizing strengths, promoting independence, and focusing on safety is implemented into geriatric care.

Implied consent:

actions taken by the nurse followed by willingness to receive or participate in those actions * Psych hospitals: -have a requirement to obtain informed consent for every medication

Psychiatric Home Care:

can be provided by any mental health professional

Admission and Discharge Procedures:

courts have recognized involuntary civil commitment into a mental hospital as a "massive curtailment of liberty" ^ so what about involuntary admissions??? *5th Amendment: no person shall be deprived of life, liberty, or property without due process of law *14th Amendment: explicitly prohibits states from depriving citizens of life, liberty, and property w/o due process of law * writ of habeas corpus: formal written order to "free the person" -is the procedural mechanism used to challenge unlawful detention by the government * least restrictive alternative doctrine: mandates that the least drastic means be taken to achieve a specific purpose ex: if a pt can be treated for depression at home (outpatient basis), hospitalization would be too restrictive and unnecessarily disruptive! * recall that both the writ of habeas corpus and the least restrictive alternative doctrine are the most important concepts applicable to civic commitment cases.

What is the goal of recovery?

empower those with mental illness to find meaning and satisfaction in their lives, realize personal potential, and function at their optimal level of independence. *contributing factors: -supportive relationships -social inclusion -acquisition of needed coping skills -recovery-oriented services -sense of hope for future

EVB:

extends to treatment approaches in which there is scientific evidence for psychological and sociological treatment methodologies, as well as evidence related to the neurobiology or psychiatric disorders and psychopharmacology. -strives to decreases the gaps between research and practice

State Acute Care System:

for those NGRI (not found guilty for reason of insanity); must be submitted somewhere * ex: women drowned her 5 children because she believed she was saving them from their sinfulness

General Hospital Psychiatric Units and Private Psychiatric Hospital Acute Care:

free-standing facilities * part of the shift away from institutionalization in state-managed hospitals

Approval and Disapproval

giving approval becomes very complex because it involves judgement.. * if a pt continues to do a said " good behavior" for the nurse, it is being done to please another person and it is not coming from the individual's own volition or conviction also once the nurse leaves, the behavior may disappear giving approval also stops communication * a more therap. approach: " I noticed that you spoke up to John in group yesterday about his rude behavior. How did it feel to be more assertive?" ^ the benefits of saying this^: -opens channel for finding out how the pt really felt -suggest that this was a self-choice the patient made -pt is given recognition for their behavior, and the topic is also opened for further discussion :) * disapproving: is moralizing and implies that the nurse has the right to judge the patients thoughts and feelings!!! ^ this is not therapeautic!!! 1) disapproving: you really should not cheat, even if you think everyone else is doing it." 2) More therp approach:): " can you give me 2 examples of how cheating could negatively affect your goal of graduating?"

Medical Diagnosis and the DSM-5:

in the DSM-5 the mental disorders are conceptualized as clinically significant behavioral or psychological syndromes or patterns that occur in an individual and that are associated w DISTRESS or DISABILITY * DISTRESS: painful symptom * DISABILITY: impairment in 1 or more areas of functioning or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom. * recall that these syndromes or patterns must not be merely an expected and culturally response to a particular event, such as the death of a loved one. * whatever the original cause, it must currently be considered a manifestation of a behaviorial, psych, or biological dysfunction in the individual within the individuals's cultural boundaries. * recall that "deviant" behavior is not considered a mental disorder unless the deviance or conflict is a symptom of a dysfunction in the individual. * it is important that the DSM classifies disorder that ppl have and not the person ^for this reason the DSM avoids using wording like, "schizophrenic" or an "alcoholic" ^ uses things more like " an individual w schizophrenia" or " an individual with alcohol dependence" * important to practice cultural competence; assessment can be particularly challenging if the clinician is from a different ethnic/cultural/minority group

Common Liability Issues:

legal issues common in psych setting relate to RN failure to protect safety of patient -issues of sexual misconduct have been a concern in psych community -misdiagnosis has also been a problem -violence is seen at an increasing rate in society and in the psych workplace

Psychiatry and Spirituality:

many leaders of nursing have advanced the importance of spirituality in nursing -psych is beginning to comprehend the importance of spiritual belief * recall that spirituality is a much broader concept that religion alone * spirituality: provides an essential core, enriching experience, and reason to live for many people * ex: seeing or hearing a deceased relative during bereavement may be misdiagnosed as manifestations of a psychotic disorder ^ syndrome may manifest in different superficial forms in different cultures. * Meditation: has many health benefits; valuable tool for dealing with chronic stress/pain * avoid labeling and stereotyping when a medical/nursing diagnosis is being formulated; recall that every society has its own view of health and illness and its own classification of diseases. * stigma: acknowledged to be a major barriers to mental health treatment and recovery to people with mental health disorders. -collection of negative attitudes, beliefs, thoughts, and behaviors that influence the individual, or the general public, fear, reject, or avoid, be prejudiced, and discriminate people. - an attribute that is deeply discrediting where a person is reduced from a whole unusual person to a tainted and discounted one *sterotyping, labeling, separating, status, loss, and discrimination; all attribute to stigmatizing *stigmatizing attitudes towards the mentally ill can have harmful effects on an individual and family especially if the diagnosis is based on insufficient evidence ^ result in social isolation and reduced opportunities * can really cause treatment blocks!!! ^^^ can directly impact the patient's recovery * common examples of cultural and social stigmatizing when making a bias on psychiatric diagnosis is the inclusion of homosexuality as a psych disease in both the 1st and 2nd editions of the DSM ^ all research consistently failed to demonstrate that people with a homosexual orientation were any more maladjusted than heterosexuals, but despite the research data, change only occurred in the medical community only when gay rights' activists advocated an end to discrimination against the LGBT community

Mental illness

medical condition that affects a person's thinking, feeling, mood, and ability to relate to others, and daily functioning. can be seen as a result of a chain of events that includes: -flawed biological, psychological, social. and cultural processes -however, mental illness is treatable and individuals can experience relief from their symptoms w treatment and support. -recovery is always a possibility even if there is no cure !

Obtaining treatment for phsical v. psychiatric disorders:

mental: treatment is often delayed over several yrs/decades physical: intermediate intervention

Medicare:

national program provides care to those who are 65 age and older as well as those who have become officially disabled * in mental illness, coverage may be 50% as opposed to 80% for nonmental outpatient care ^ only pays mental health care for those in extreme financial need

Negligence and Malpractice:

negligence/malpractice: an act or omission to act that breaches the duty of due care and results in or is responsible for a person's injuries * 5 elements required to prove negligence: 1) Duty: measured by standard of care; when nurses rep themselves as being capable of caring for psych patients and accept employment, a duty of care has been assumed. * if you're not capable of providing the standard of care that other nurses would be expected to provide under similar circumstances, you have breached the duty of care. 2) Breach of Duty: conduct that exposes the patient to an unreasonable risk of harm through either commission or omission of acts by the nurse. -RN must have required education and experience. 3) Cause in fact: may be evaluated by asking the question, "except for what the nurse did, would this injury have occurred?" 4) Proximate Cause: aka legal cause; may be evaluated by determining whether there were any intervening actions or individuals that were in fact the causes of harm to the patient 5) Damages: INCLUDE ACTUAL DAMAGED; loss of earnings, medial expenses, property damage * Foreseeability of harm: evaluates the likelihood of the outcome under the circumstances.

mental health

not specific entities but rather they exist on a continuum ranges from mild, moderate, severe to psychosis recall that mental health is from early childhood until death the "springboard of thinking and communication skills, learning, emotional growth, resilience, and self-esteem * also recall that it is a state of well being in which individuals are able to realize their abilities within the normal stresses of life and function productively within their personal lives as well as contribute to their community.

Role of psychiatric nurses in inpatient care settings:

nurses are at the center of any acute care inpatient facility mgmt by these units, ideally, is by nurses w/ backgrounds in psychiatric mental health nursing, preferably w/ advanced practice degrees. * Duties of Staff psychiatric RN: 1) completing comprehensive data collection that includes the patient, family, and other health care workers. 2) making and implementing plans of care 3) assisting or supervising mental health care workers 4) maintaining a safe and therapeutic environment 5) facilitating health promotion through teaching 6) monitoring behavior, affect, and mood 7) maintaining oversight of restraint and seclusion 8) coordinating care by the treatment team * nurses play a huge role in the decision making process of medication administration * medication management is an essential skill for psychiatric nurses * feedback about a patient's excessive sedation or increased agitation will lead to a decision to decrease or increase dosage in the antipsychotic med * common misperception regarding pysch nurses is that they lose their skill because they "just talk" 1) therapeutic communication is a learned skill 2) pts on a psych unit are not limited to medical diagnoses' often have complex health care needs. * wound care and insulin administration must still be carried out if a patient is in a psych unit for suicidal tendencies.

Patient Rights Involving Involuntary Commitment and Psychiatric Advance Directives:

patients concerned that they may be subject to involuntary psychiatric commitment can prepare an ADVANCE PSYCHIATRIC DIRECTIVE DOCUMENT that will express their treatment choices -recall advance directives should be used for mental health decision-making when the patient is not competent to make decisions for themselves * the document will clarify the patient's choice of a surrogate decision maker, instructions about hospital choices, medications, and treatment options as well as emergency interventions

Civil Rights:

ppl with mental illness are guaranteed the same civil rights as any other citizen under both federal and state laws!!! ^ NO MATTER WHAT -UNLESS the pt has lost LEGAL capacity by being incompetent note that the mentally ill in jails and prisons are afforded the same protections -courts usually attempt to direct the offender to treatment and services in the community

Epidemiology

quantitative study of distribution of disorders in human populations. epidemiologists can identify high-risk groups and high risk factors - the study of these high risk factors can lead us to clues about the etiologies of various mental disorders. clinical epidemiology addresses the outcomes ofppl with illnesses who are seen by providers of clinical care * recall that results of clinical epidemiology are now routinely includes in the DSM to describe the frew of mental disorders ^ can assess the freq w/ which symptoms appear concurrently.

Patient-Centered Medical Homes (PCMH) aka primary care medical homes:

received strong support from the affordable care act under obama -developed in response to fragmented care that resulted in some services never being delivered while others were duplicated; the focus of care is patient-centered and provides access to physical health, behavioral health, and supportive community and social services. ^ services range from preventive care and acute medical problems to chronic conditions and end-of-life issues. Characteristics of these homes: 1) Patient-Centered: based on patient and family -takes into account the unique needs of whole person -pt is a core member of the mgmt team 2) Comprehensive Care: -all levels -preventive, acute, and chronic -physicians and advanced practice nurses lead teams that include nurses, PA's, pharmacists, nutritionists, social workers, educators, and care coordinators. 3) Coordination of Care: care is coordinated w the broder health system such as hospitals, specialty care, and home health 4) Improved Access: patients do not wait mon-fri from 9am-5pm to get the care they need in addition to extended hrs of services, these homes provide email and phone support 5) Systems Approach: evidence-based care is provided w a continuous feedback loop of evaluation and quality improvement. * Community Mental Health Centers: devloped from president Kennedy' scommunity Mental Health Centers Act of 1963 signaled a new policy preference for community care as opposed to institutionalization CMHC's: are regulated through mental health depts and funded by the state -fees are typically determined using a sliding scale Communiy-based facilities provide comprehensive services to prevent and treat mental illness ^ these services include assessment, diagnosis, individual and group counseling, case mgmt, medication mgmt, education, rehabilitation, vocational/employment services. * some offer services across the life-span, whereas others may be population specific such as adult, geriatric, or children

Psychiatric Nursing:

specialized area of nursing practice that focuses on the treatment of human responses to mental health problems and psychiatric disorders

Diagnostic and Statistical Entities Manual of Mental Disorders DSM-5

the current official guidebook for categorizing and diagnosing psychiatric mental heal disorders in the US * primary objective: provide clinicians, researchers, psychiatric drug regulation agencies, health insurance companies, pharmacological companies and policy makers w a common language and standard criteria for the classification of mental disorders. * organizes each psychiatric diagnosis into 5 levels of axes relating to different aspects of disorder or disability. axis 1: referred to the collection of signs and symptoms that together constitute a particular disorder (ex: schizophrenia; condition that may be a focus of treatment) axis 2: referred to PERSONALITY DISORDERS and MENTAL RETARDATION Thus axes 1 and 2 constitute the classification of abnormal behaviors -recall that LATER AXES 1 AND 2 were separated to ensure that the possible presence of long-term disturbance is considered when attention is directed to the current disorder. axis 3: clinician indicated any general medical conditions believed to be relevant to the mental disorder in question -sometimes a neurological disorder is the cause of abnormal behavior (ex: lesion on the brain causes impulsive behavior= murder) axis 4: for reporting psychosocial and environmental problems that ay affect diagnosis, treatment and prognosis of the mental disorder * may include: occupation, educational, economic, interpersonla problems or difficulties w family members * psychosocial assessment will often uncover these axis 5: Global Assessment of Functioning; indication of the person's best level of pyschological, social, and occupational functioning during the preceding year rated on a scale of 1-100 (1 is danger of hurting themselves and 200 is superior functioning DSM-5 no longer uses an axial system; now uses International Classification of Disease Codes

Vision for Mental Health Care in America:

unfortunately there are many ppl who do not have access to mental health care at all - rural areas do not always provide mental health services -recall that many families can't even afford insurance.. * over the next 2 decades: GOALS 1) americans will understand that mental health is essential to overall health; perhaps it will become LESS stigmatized 2) Mental health care is consumer and family driven 3) disparities in mental health services need to be eliminated!!! 4) excellent mental health care needs to be delivered and research needs to be accelerated! 5) Technology is used to access mental health care and information