Mental Health

Nursing II
NURS 2310
Unit 1
Basic Concepts of
Mental Health and
Mental Illness

Objective 1
Exploring the historical
overview of care of the
mentally ill client

In the Beginning
No known treatment for the mentally
ill before 1840
Mental illness perceived as incurable
Only reasonable intervention was
removing mentally ill persons from the
community

The Birth of Community Mental Health

Provided for reimbursement of mental
health services through Medicare and
Medicaid
Resulted in the deinstitutionalization
of the mentally ill

Deinstitutionalization of the Mentally Ill

The deinstitutionalization movement
occurred throughout the late 1950s
and early 1960s
500,000 people lived in state mental
hospitals in 1955
Right to freedom at issue
Communities

unable to sustain care

for mentally ill

Insufficient planning
Budget cuts reduced mandated services
Mentally ill became homeless
Outcome is revolving door syndrome

The Problems That Remain

The mentally ill comprise a great
majority of the homeless population
Many person with chronic mental illness
end up in jails and emergency rooms
Not enough community services/facilities
to provide adequate care for mental
illness
Medicaid, Medicare, and other 3 rd-party
payers do not reimburse mental health
services at the same rate as medical
services
Continuing stigma of mental illness

Objective 2

Reviewing concepts related to

mental health and mental
illness

Mental health
The successful adaptation to stressors from
the internal or external environment,
evidenced by thoughts, feelings, and
behaviors that are age-appropriate and
congruent with local and cultural norms.
Mental illness
Maladaptive responses to stressors from the
internal or external environment, evidenced
by thoughts, feelings, and behaviors that
are incongruent with local and cultural
norms, and interfere with the individuals
social, occupational, and/or physical
functioning.

Self-esteem
Ones opinion of oneself; a confidence and
satisfaction in oneself.
Self-awareness
An awareness of ones own personality or
individuality.
Sanity
Soundness or health of mind; ones ability
to bear legal responsibility for ones
actions.
Resilience
Ability to recover from or adjust easily to
misfortune or change.

Well-being
The state of being happy, healthy, or
prosperous.
Empowerment
To promote the self-actualization or
influence of.
Assertiveness
The expression of opinions, needs, and
feelings without negating the opinions,
needs, and feelings of others.

Objective 3

Identifying members of the

mental health team and their
roles

Psychiatrist

Medical doctor with special training in mental

illness and behavioral/emotional problems
Diagnoses conditions and prescribes medical
treatment

Clinical psychologist

Provides individual and group therapy

Performs psychiatric testing

Therapist

Provides individual therapy

Conducts group therapy sessions

Social worker

Community resource education

Discharge planning

Recreation therapist

Incorporates leisure activities in group settings

to demonstrate healthy coping mechanisms

Nurse

Administers medications
Conducts group education sessions
Provides patient support and directs patient
care

Psychiatric technician

Assists nursing staf

Provides support to client

Objective 4

Reviewing the ANA

Standards of Psychiatric
and Mental Health Nursing
Practice

The American Nurses Association (ANA)

has identified five standards of
psychiatric and mental health nursing
practice:
Standard I
Assessment
Standard II
Diagnosis
Standard III
Outcome Identification
Standard IV
Planning
Standard V
Implementation
Standard V includes milieu therapy,
promotion of self-care activities,
psychobiological interventions, health
teaching, case management, health
promotion and health maintenance

Objective 5
Describing the
composition of
the Board of
Mental Health
in Nebraska
and Iowa

Iowas mental health committals are handled

by the county court in which the ill
individual resides.
The Board of Mental Health in Nebraska
consists of:

2
2
2
2
2

licensed mental health practitioners

certified marriage and family therapists
certified master social workers
certified professional counselors
public members

Members of the BOMH serve for 5 years,

with no more than 2 consecutive 5-year
terms.
At least one member of the board must be a
member of a racial or ethnic minority.

The professional members of Nebraskas

BOMH must meet the following
requirements:

Be actively engaged in the practice of his/her

profession

Be working in his/her profession within the

State of Nebraska

Be working under a license issued in this

state

Have a 5-year history of working in his/her

profession just preceding the appointment

The public members of Nebraskas BOMH

must meet the following requirements:

Be a resident of this state

Attained the age of majority

Represent the interests and viewpoints of

consumers

Not be a present or former member of a

credentialed profession, an employee of a
member of a credentialed profession, or an
immediate
family or household member of
any person presently regulated by such board

Objective 6

Examining psychiatric client

rights

Universal Bill of Rights for Mental Health

Patients
Mental Health Systems Act of 1980
Right

to the least restrictive treatment

alternative

Right

to informed consent

Right

to refuse treatment

Right

to confidentiality

Right

to keep personal items

Right to the least restrictive treatment

alternative
The

nurse must attempt to provide

treatment in a manner that least restricts
freedom
Right to informed consent

Informed

consent is the clients

permission to perform treatment
Legal liability for informed consent lies
with the physician
The nurse acts as the clients advocate to
ensure informed consent was obtained

Right to refuse treatment

The

patient has the right to refuse

treatment to the extent permitted by
law, and to be informed of the medical
consequences of his or her action
Right to confidentiality

Pts

privacy is protected by
Amendments IV, V, and XIV
Protection of client records and
communications per state statute

Right to keep personal items

People in a hospital or other treatment
facility retain the right to keep their
personal possessions
Items must be protected and returned
upon release from the facility
Exceptions include:

the belonging poses a serious threat to self

or others
items that may be dangerous would be held
in a secure place during hospitalization
personal items must be returned to the
client upon release from the facility
(each facility has own guidelines regarding
confiscated illegal items)

Psychiatric patients have the right to

freedom from restraint or seclusion
except in an emergency situation:
Restraints or seclusion are used for an
individual whose behavior is out of
control and who poses an inherent risk
to the physical safety and psychological
well-being of the individual and staf or
others.

Restraints or seclusion are never used for

punishment or for the convenience of staf.
Mechanical Restraints
set of leather straps
5-point maximum use
2-point minimum use

used to restrain the extremities of the individual

individual is always in seclusion if in restraints
Physical Restraints
Seclusion (solitary confinement in a locked room)
Holding (used with smaller children)

Requires 1:1 supervision

Restraints and Seclusion Guidelines

Restraints or seclusion can be initiated
without a physicians
order in an emergency

Physician must be notified for an order

within 1 hour of initiation

Renewal of restraint or seclusion orders

Every 4 hours for adults

Every 2 hours for children 9 years and older

Every 1 hour for children younger than age 9

Restraints and Seclusion Guidelines

(contd)
In-person evaluation of individual in
restraints or seclusion by the physician

Within 4 hours of initiating restraints or

seclusion for an adult
Within 2 hours of initiating restraints or
seclusion for a child

In-person re-evaluation of individual in

restraints or seclusion by the physician

Every 8 hours for an adult

Every 4 hours for a child

The nurse must assess and document

circulation, respiration, nutrition, hydration,
and elimination every 15 minutes

Concepts related to the Right to Freedom

False imprisonment = the deliberate and
unauthorized confinement of a person
within fixed limits (can be verbal or
physical)
may include taking a clients clothes for
purposes of detainment against his or her will

Assault = an act that results in a persons

genuine fear and apprehension that he or
she will be touched without consent
Battery = the touching of another person
without consent (harm or injury may or may
not occur

Major Elements of Informed Consent

Knowledge
Competency
Free will
Treatment may be performed without
obtaining informed consent under these
conditions:
The client is mentally incompetent to make a
decision and treatment is necessary to preserve
life or avoid serious harm
Refusal endangers the life or health of another
An emergency situation
Client is a minor
Therapeutic privilege (full disclosure would
complicate treatment, cause severe psychological
harm, or be so upsetting as to render a rational
decision impossible)

Objective 7
Discussing confidentiality in
psychiatric care

Health Insurance Portability and

Accountability Act (HIPAA) of 1996
The individual has the right to access his/her

medical records
The individual has the right to have corrections
made to his/her medical records
The individual has the right to decide with
whom his/her medical information may be shared

Breach of Confidentiality
Revealing aspects about a clients case
Revealing that an individual has been
hospitalized

Defamation of Character
Sharing of malicious and false information
that is detrimental to an individuals reputation
Client may seek legal restitution if making
the information known resulted in harm
Libel = information shared in writing
Slander = information shared orally

Invasion of Privacy

Searching a client without probable cause

Objective 8
Discussing criteria for
hospitalization of a mentally ill
client

In order to be considered eligible for

admission to an acute inpatient
psychiatric unit, an individual must meet
one or more of the following criteria:
The client is an imminent threat to
himself/herself
The client poses an imminent threat to
the safety and/or well-being of others
The client is unable to provide for his/her
basic needs in spite of having adequate
resources
The client is out of control

Objective 9
Comparing voluntary
hospitalization, involuntary
hospitalization, and
involuntary commitment

Voluntary Hospitalization
Admission process similar to medical
hospitalization
Patient may stay as long as treatment is
deemed necessary
Patient can leave at any time

Involuntary Hospitalization
Client is hospitalized without consent
Situation must be considered an emergency
Client receives observation and treatment for
mental illness
May occur when an individual is unable to take
care of his/her basic needs in spite of having
adequate resources to do so

Involuntary Commitment
In the State of Nebraska, an individual can
be involuntarily committed subject to due
process and as a result of being a danger to
self or others as manifested by:

Recent threats or acts of violence

Substantial risk of serious harm

evidenced by inability to provide for basic
human needs, including food, clothing,
shelter, essential medical care, or personal
safety

Types of Involuntary Commitment

Voluntary commitment via a guardian

Emergency Protective Custody (EPC)

Physician hold

Board of Mental Health hold

Board of Mental Health commitment

Voluntary Commitment via a Guardian

Guardian may voluntarily commit ward to a
mental health treatment facility
No due process required

Emergency Protective Custody (EPC)

Police custody
36-hour time limit
Terminates automatically or by county
attorney intervention

Physician Hold

May follow EPC or voluntary admission

48-hour time limit

Board of Mental Health (BOMH) Hold

Petition can be filed by anyone at any time
Petition must include sufficient documentation
that an individual is at imminent risk of harming
self/others
Once approved, client brought to
hospital/psychiatric facility

BOMH hearing set for 7 calendar days

Client served with copy of BOMH petition
Client has the right to attend hearing and be
represented by an attorney

Physician can drop petition after assessment

of client with approval from the county attorney

Board of Mental Health (BOMH) Commitment

BOMH determines whether a client should be
involuntarily committed to inpatient or outpatient
treatment during the BOMH hearing following the
filing and approval of the petition
BOMH treatment plan must be approved during
the process of the hearing as this directs clients
care throughout his/her commitment
Committal must be reviewed periodically, as well
as upon appeal by client/clients attorney or
physician
Ultimate goal of the BOMH is to use the least
restrictive means possible to ensure the client
receives necessary treatment