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Psychiatric-Mental Health Nursing

Katherine Conlu-Bengan, RN

UNIT I. FOUNDATIONS OF PSYCHIATRIC-MENTAL HEALTH NURSING

Entering Psychiatric Nursing

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Difference Between Psychiatric and Medical-Surgical Nursing

Physical efforts prove to students that they are working and accomplishing something. In psychiatric nursing one has to be psychologically active, but physically passive much of the time.

It takes some time to realize that LISTENING to what aches in the hearts of patients may touch them more profoundly than back rub.

How will I handle bizarre or inappropriate behavior?

What happens if a client asks me for a date or displays sexually aggressive or inappropriate behavior?

What if I say something wrong?

Am I prying when I ask personal questions?

What if no one will talk to me?

What will I be doing?

What if I encounter someone I know being treated on the unit?

Is my physical safety in jeopardy?

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DEFINITION OF HEALTH
a state of complete physical, mental and social well-being

without the absence of disease or infirmity

WORLD HEALTH ORGANIZATION

DEFINITION OF MENTAL HEALTH

the successful performance of mental function, resulting in productive activities, fulfilling relationships, and the ability to adapt to change and cope with adversity
(USDHHS, 1999)

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DEFINITION OF MENTAL HEALTH

I probably A state of emotional, have the psychological, and social most sanest mind..hehe wellness evidenced by satisfying interpersonal relationships, effective behavior, and coping, positive self-concept, and emotional stability.

ELEMENTS OF MENTAL HEALTH

Self-governance Progress toward growth or self-realization Tolerance of uncertainty Self-esteem Reality orientation Mastery of environment Stress management

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INFLUENCES ON MENTAL HEALTH

Biological factors
Biologic makeup Sense of harmony in life Emotional resilience/hardiness Spirituality Positive identity

kcbengan/SACRNursing/2004

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Social and Cultural factors

Sense of community Access to adequate resources Intolerance of violence Support of diversity among people

kcbengan/SACRNursing/2004

Interpersonal factors
Effective communication Ability to help others Intimacy Balance of separateness and connection

kcbengan/SACRNursing/2004

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DEFINITION OF MENTAL ILLNESS

a clinically significant behavioral or psychological syndrome experienced by a person, marked by distress, disability, or the risk of suffering, disability, or loss of freedom
(American Psychiatric Association)

Psychopathology
Psychopathology examines the nature and development of abnormal
Behavior, Thoughts, Feelings

Definitions of abnormality vary widely and may not capture all aspects of psychopathology
Psychopathological aspect (causes, mechanisms) Clinical aspect (assessment, treatment)
Ch 1.1

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Early Views of Psychopathology

Demonology (Supernaturalism) is the view that abnormal mental function is due the occupation by an evil being of the mind of a person Treatment requires exorcism Somatogenesis is the view that disturbed body function produces mental abnormality Psychogenesis is the belief that mental disturbance has psychological origins

Demonology During the Dark Ages

The Dark ages were marked by a decline in Greek and Roman civilizations and by an increase of influence of churches Church authorities came to view witchcraft as an explanation of abnormality
Witches were in the league with the Devil Torture was required to elicit confessions of witchcraft; death by fire was required to drive out supposed demons

Ch 1.5

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TREPHINATION

Asylums
Asylums were created in the 15th century for the care/treatment of the mentally ill.
Asylums were meant to be a place of refuge Care and treatment within an asylum was not always humane or effective

Pinel (1793) advocated for humane treatment of patients in asylums (moral treatment)
Removed shackles, improved diet, better treatment

Ch 1.6

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Systems of classification were developed which argued that mental illness has a biological cause
Kraepelin suggested that clusters of symptoms form a syndrome
Each syndrome has its own unique cause, course, symptoms, treatment, and outcome

Freud: emphasized the importance of early life experiences Bleuler: was optimistic about treatment
Ch 1.7

If some mental disorders are caused by chemical imbalances then chemicals could restore the balance; people would no be longer need to be confined A destigmatization of mental illness occurred; parents and others not to be blame; terms least restrictive environment evolved from this discovery

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1949 Lithium 1950 first antipsychotic 1952 MAOIs 1957 Haloperidol 1958 TCAs 1960 - Benzodiazepines

Individuals do not need to be hospitalized away from families and community; people have the right to be treated in their own community Desinstitutionalization Advantage: Intervention in familiar surroundings has helped many people, is less expensive

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Desinstitutionalization
Refers to the depopulating of state mental hospitals OTHER PROGRAMS:
Emergency care
24-hour inpatient care Outpatient care

Consultation and education for the population served by the center

Screening devices

If we can understand the brain, we can help millions of people suffering from mental disorders. An increase in the funding fro brain research, leading to new treatment strategies, has increased our understanding of mental disorders.

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TRANQUILIZER CHAIR

O'HALLORAN'S SWING

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HYDROTHERAPY

LUNATIC BOX

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HOLLOW WHEEL

RESTRAINT CAGE

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Benjamin Rush

Clifford Beers

Sigmund Freud

Emil Kraepelin

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THERAPEUTIC COMMUNICATION

Hildegard Peplau

PSYCHIATRIC NURSING IN THE PHILIPPINES

Pre-Spanish regime The Spanish Rule The American Rule The Japanese occupation The Liberation Period and The Era of the Republic Present-Day Psychiatry

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PRE-SPANISH REGIME
In order to receive blessing, they need to maintain a harmonious relationships with the material and spiritual worlds. Spirits Babaylan (shaman), sorcery healing

The Spanish Rule (1565 to 1898)

Mental illness was caused by an act of sorcery Mangkukulam and Manggagaway Herbolarios
they were also brought to the church for exorcism or purification. Some patients were wrapped with mats and whipped by bamboo sticks or the tail of buntot pagi (stinger fish). Those who suffered from hysteria were unexpectedly thrown into the river.

Early 19th century:

Hospico de San Jose

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The American Era (1898 to 1942 )

The concept of mental illness was founded on the biomedical phenomenon.
Treatments were scientific and mechanistic in approach. Also, the discovery of somatic therapies strengthened the biological explanation of psychiatric illness. Several treatment centers for mentally ill individuals in the Philippines were established. Insane Department was opened as the San Lazaro Hospital (1904) Dr. Elias Domingo: first physician to obtain formal training in the US

1928: The Insular or National Psychopathic Hospital (NPH) was erected in Mandaluyong, Rizal. This was the first hospital that catered exclusively to the treatment of mentally ill patients in the Philippines.
Manic patients were treated with fever therapy, metrazole shock, insulin shock therapy, prolonged narcosis, R1651 hyoscine injections (bromides), and hydrotherapy.

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The Japanese Occupation (1942-1945)

National Psychopathic Hospital continued to operate The remianing patients and a few employees of the hospital were executed for alleged anti-Japanese activities The Japanese Imperial Army donated an electroshock apparatus

The Liberation Period and the Era of the Republic (1945 to 1960)
National Mental Hospital Dr. Jose A. Fernandez as OIC from October 1946 to April 1961 Improve basic services for patients, development of infrastructure with the construction of additional building for those who can pay for mental health services

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One-Dimensional Models

ONE CAUSE
Multidimensional Models

DISORDER

MANY CAUSES

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Social Influences

Biological Influences

Behavioral Influences

Cognitive & Emotional Influences

PROBLEMS IN TREATING MENTAL ILLNESS

Cost-related issues Stigma Revolving door treatment Lack of parity Limited access to services

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METHODS OF ACHIEVING OPTIMAL CARE FOR MENTAL ILLNESS

Beyond response to recovery Reintegration into society Mental health parity Culturally competent care Medication adherence

PSYCHIATRIC-MENTAL HEALTH NURSING

the diagnosis and treatment of human responses to actual or potential mental
health problems

(ANA, APNA, & ISPN, 2000)

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Psychiatric-Mental Health Nursing

Nursing Process and Standards of Care Levels of Practice Guiding Principles Role of the Psychiatric Nurse as a Team Member

Nursing Process and Standards of Care

A scientific, problem-solving method that assists nurses in total client care. 5 Steps:
Assessment

Planning Nursing diagnoses

Intervention Evaluation

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PERSONAL PHILOSOPHY ISSUES

Self-Awareness The NURSE gains recognition of his/her Awareness of Environment Includes recognition of

own feelings, beliefs, and attitudes.

client needs, belief systems, and behaviors; identification of the factors that contribute to health and illness in the client; and assessment of
resources available to the client.

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Awareness Of Interactions With The Environment

NURSES identify their: > specific feelings and thoughts about clients

(including feelings of acceptance or rejection)

> evaluate the consequences of their actions toward clients > learn to effectively differentiate between their own needs and client needs.

An interpersonal process Employing theories of human behavior as its science and purposeful use of self as its art. The major therapeutic goal is the prevention, detection, and rehabilitation of psychiatric disorders.

Emphasis on the interpersonal process and relationships Most fundamental goals : To help the patient accept himself, to improve his relationship with other people and to learn to function independently on a realistic basis.

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Psychiatric Nursing Paradigm

Human behavior

Therapeutic Use of self

Communication skill
Nursing Process

Other Terms Used For Psychiatric Nursing: Psychosocial Nursing Institutional Nursing Mental Health Nursing

Self as a Therapeutic Tool

Nurse uses herself in order to affect positive changes in the patients behavior.

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Principles and Perspectives of the Psychiatric-Mental Health Nurse

Principles of Psychiatric Nursing

View the client as a holistic being Focus on the clients strengths and assets, not on his weakness and liabilities Accept the client as a human being who has value and worth View the clients behavior as designed to meet a need or to communicate a message Potential for establishing relationship with clients Quality of the interaction View the clients behavior as the best possible adaptation

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Essential Qualities of the PsychiatricMental Health Nurse

Therapeutic Use of Self Genuineness and Warmth Empathy Acceptance Maturity and Self-Awareness

Nursing Scope of Practice

Standards of care and practice for psychiatric mental health nurses were developed by the American Nurses Association and continue to describe functions.

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Basic Practice Level

At the basic practice level, nurses can intervene in the following ways: Counseling
described by the ANA as including interviewing and communication techniques, problem solving, crisis intervention, stress management, and behavior modifications

Basic Practice Level (cont.)

Milieu Therapy The environment is used as a therapeutic tool to modify behaviors, teach skills, and encourage communication between the client and others. Self-Care Activities Encouraging independence within a clients ability and capacity urges clients to take responsibility for their care thus improving their self esteem.

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Basic Practice Level (cont.)

4. Psychobiologic Interventions
Knowledge of medications used in the psychiatric setting

5. Health Teaching
6. Health Promotion and Health Maintenance 7. Case Management Coordinates comprehensive health services and ensures continuity of care

Advanced Practice Level

The following interventions may be employed by clinical specialists and nurse practitioners who are certified in advanced psychiatric mental health nursing:
1. 2. 3. 4. Psychotherapy Prescription of Pharmacologic Agents Consultation Education

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The Mental Health Team

Nurse Social Worker Clinical Psychologist Psychiatrist Physician Occupational Therapist Recreational Therapist Psychiatric Aide/Clinical Assistant

Roles of the Mental Health Team

Psychiatric Nurse
Has the most widely focused position description of any of the member roles
Interacts with clients in individual and group settings Manages client care Administers and monitors meds Teaches both clients and families Acts as a client advocate

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NURSING ROLES

Ward Manager Social Agent

Counselor

Teacher

Mother Surrogate Technical Role

Roles of the Mental Health Team

Psychiatric Social Worker
Graduate level position
Work with clients on an individual basis Conduct group therapy sessions

Act as liaisons with the community to place clients after discharge

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Roles of the Mental Health Team

Psychiatrist
Licensed medical physician who specializes in psychiatry

Prescribe and monitor meds Admit clients into acute care settings Administer ECT Conduct individual and family therapy

Roles of the Mental Health Team

Psychologist
Licensed individual with a doctoral degree in psychology Assess and treat psychologic and psychosocial problems of individuals, families, or groups Do not prescribe or administer medications Administer psychometric tests that aid in the diagnosis of disorders

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Roles of the Mental Health Team

Marriage, Family, Child Counselor
Licensed individuals who frequently work in private practice

Prepared to work with individuals, couples, families, and groups

Emphasize the interpersonal aspects of achieving and maintaining relationships

Roles of the Mental Health Team

Case managers
Facilitate the delivery individualized, coordinated care in cost-effective ways
Need to know the various types of hospitalization and outpatient care settings, the coverage offered by different payers, and the impact of state and federal legislation

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MULTI-AXIAL SYSTEM OF DIAGNOSIS

AXIS I: Clinical Disorders AXIS II: Personality Disorders and Mental Retardation AXIS III: General Medical Conditions AXIS IV: Psychosocial and Environmental Problems AXIS V: Global Assessment of Functioning (GAF); 0-100
(APA, 2000)

Therapeutic Rx Modalities
Traditional inpatient hospitalization has been replaced with an entire range of care options Rx options include:
Inpatient hospitals Outpatient day treatment programs Clinics Home care Community centers

Crisis centers
Place of employment/school

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Therapeutic Rx Modalities (cont.)

Types of Therapies
Interactive therapies- includes all of those in which the client has interpersonal contact with 1 or more therapists and includes interaction with other clients Biologic therapies- includes the use of medications and ECT

Prevention of Disorders
Gerald Caplan (1964) proposed a model for preventive care of persons with mental disorders. Model proposes 3 levels of preventions
Primary Secondary Tertiary

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Primary Prevention
Focuses on reduction of the incidence of mental disorders within the community Emphasizes health promotion and prevention Example: Teaching stress reduction techniques to any population

Secondary Prevention
Directed toward reducing the prevalence of mental disorders through early identification and early Rx of those problems Example: assessing sx of depression such as sleep disturbances, appetite changes, diminished interest during routine interview with client; if problem identified- treat

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Tertiary Prevention
Has the dual focus of reducing residual effects of the disorder and rehabilitating the individual who experienced the mental disorder Example: Social skills training to a schizophrenic

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