Introduction to Psychiatric Introduction to Psychiatric Nursing Nursing

Test QuestionsTest Questions

• Legal Aspects: CommitmentsLegal Aspects: Commitments

• Assessment of the mental health Assessment of the mental health clientclient– Mental Status ExamMental Status Exam

Test QuestionsTest Questions• Assessment of the mental health Assessment of the mental health

clientclientNurse/ patient relationship Nurse/ patient relationship

Stages and Phases Stages and Phases

– Communication TechniquesCommunication Techniques

Neurobiology: Not on the Neurobiology: Not on the TestTest

Test QuestionsTest Questions

• Neurobiological Concepts Neurobiological Concepts

• Practice tests on BlackboardPractice tests on Blackboard

Social ValuesSocial Values

• Individual FreedomIndividual Freedom• MoneyMoney• Paternalism vs LibertarianismPaternalism vs Libertarianism

– Paternalism believes that an authority Paternalism believes that an authority knows what is best for youknows what is best for you

– Libertarianism believes that the individual Libertarianism believes that the individual knows what is best for themknows what is best for them

• No other area of nursing is so effected No other area of nursing is so effected by social values as psychiatric nursingby social values as psychiatric nursing

History ConceptsHistory Concepts

• Where were mentally ill kept doing Where were mentally ill kept doing middle ages?middle ages?– BanishmentBanishment– confinementconfinement

• What were attitudes toward them?What were attitudes toward them?– No better than wild animalsNo better than wild animals– Placed on displayPlaced on display

HistoryConceptsHistoryConcepts

• Renaissance: beginning of rationality.Renaissance: beginning of rationality.1790s1790s

• First mental hospitals in US in 1820’sFirst mental hospitals in US in 1820’s– Liberal idea of getting them out of jailLiberal idea of getting them out of jail– Who was Dorthea Dix?Who was Dorthea Dix?

• A nurse who was one of the first major A nurse who was one of the first major reformers in the United States.reformers in the United States.

• Helped develop the concept of an asylumHelped develop the concept of an asylum• Had a direct role in opening 32 state Had a direct role in opening 32 state

hospitals hospitals

Dorthea Dix Hospital in North Dorthea Dix Hospital in North CarolinaCarolina

History ContinuedHistory Continued

• Concept: if we treat patients humanely, Concept: if we treat patients humanely, and respectfully, in a bucolic country and respectfully, in a bucolic country setting, they will improve.setting, they will improve.– Unchained Unchained – ClothedClothed– Aspired to the philosophy that mental illness Aspired to the philosophy that mental illness

worsens with stressworsens with stress

• Massachusetts hospital had cure rate of Massachusetts hospital had cure rate of 1/3, 1/3 improved and 1/3 stayed in 1/3, 1/3 improved and 1/3 stayed in hospital for life.hospital for life.

Community Mental HealthCommunity Mental Health

• Hospitals became Hospitals became overcrowded and overcrowded and bureaucratic. bureaucratic. Patients treated Patients treated cruelly.cruelly.

Medications were Medications were not available until not available until the 1950sthe 1950sClorpromazine Clorpromazine (Thorazine) for (Thorazine) for SchizophreniaSchizophreniaLithium for ManiaLithium for Mania

Community Mental HealthCommunity Mental Health

• 1963 Community Mental Health 1963 Community Mental Health Act passedAct passed

• Concept: Patients treated better in Concept: Patients treated better in community; de-instutionalization community; de-instutionalization beginsbegins

• All State Hospitals in some States All State Hospitals in some States closed.closed.

• Homelessness increasedHomelessness increased

Rights of Mental PatientsRights of Mental Patients• Right to refuse treatmentRight to refuse treatment• Right to informed consentRight to informed consent• Right to receive visitors and telephone Right to receive visitors and telephone

callscalls• Right to be treated in the least restricted Right to be treated in the least restricted

environment (Seclusion; Restraint)environment (Seclusion; Restraint)• Right to be treated with respect (must Right to be treated with respect (must

always provide for basic needs)always provide for basic needs)• DO NOT have a right to ALL PossesionsDO NOT have a right to ALL Possesions

Rights of Mental PatientsRights of Mental Patients

• Least Restrictive Environment:Least Restrictive Environment:– How Nurses should thinkHow Nurses should think– Seclusion is used when the person is Seclusion is used when the person is

a danger to othersa danger to others– Restraint is used when the person is a Restraint is used when the person is a

danger to selfdanger to self– NeverNever used to get a patient to used to get a patient to

complycomply

Rights of Mental PatientsRights of Mental Patients

• Basic Needs: Basic Needs: – Warmth: clothing a blanketWarmth: clothing a blanket– FoodFood– Access to the outdoorsAccess to the outdoors– Contact with familyContact with family

– When can this be restricted?When can this be restricted?

Legal Aspects: Legal Aspects: CommitmentsCommitments

• Mental illness as defined by the Mental illness as defined by the Mental Health CodeMental Health Code

• ““Mental illness is a disease or Mental illness is a disease or condition which either:condition which either:– Substantially impairs the person’s Substantially impairs the person’s

thought, perception of reality, emotional thought, perception of reality, emotional process or;process or;

– Grossly impairs behavior as manifested Grossly impairs behavior as manifested by a recent event of disturbed behavior by a recent event of disturbed behavior

CommitmentsCommitments

• Voluntary CommitmentVoluntary Commitment• A person 16 years of age or over signs A person 16 years of age or over signs

themselves in for admission. Person is themselves in for admission. Person is advised of their rights under the code.advised of their rights under the code.

• If a patient changes their mind about If a patient changes their mind about being in the hospital, staff have 4 being in the hospital, staff have 4 hours to file for a commitment.hours to file for a commitment.

• signs a consent to treat.signs a consent to treat.

Voluntary CommitmentVoluntary Commitment

• Most commitments are voluntary where Most commitments are voluntary where the individual or the therapist requests the individual or the therapist requests admission and the patientadmission and the patient

• The patient must sign consents for all The patient must sign consents for all psychotropic medications. If the refuse psychotropic medications. If the refuse to sign these consents the medications to sign these consents the medications can NOT be administeredcan NOT be administered

• All involuntary commitments can All involuntary commitments can include court ordered medications.include court ordered medications.

Involuntary CommitmentsInvoluntary Commitments

• Emergency Mental Illness Emergency Mental Illness CommitmentCommitment

• Allows Mental Health Deputies to pick Allows Mental Health Deputies to pick up a person who presents an up a person who presents an “IMMINENT DANGER TO SELF OR “IMMINENT DANGER TO SELF OR OTHERS” and bring them into custody OTHERS” and bring them into custody for 24 HOURS. for 24 HOURS.

• MD can file a commitment at that MD can file a commitment at that time.time.

Order of Protective Order of Protective CustodyCustody

• Commitment must be accompanied by Commitment must be accompanied by a medical certificate , which states a medical certificate , which states that the physician has examined the that the physician has examined the patient within 24 hours. This is filed at patient within 24 hours. This is filed at the County Clerks Office. There is a the County Clerks Office. There is a $300. charge for this.$300. charge for this.

• Probable Cause Hearing within 72 hrs. Probable Cause Hearing within 72 hrs. • Pt. can be committed for 14 days. Pt. can be committed for 14 days.

Temporary CommitmentTemporary Commitment

• Papers must be filed with the CourtPapers must be filed with the Court• Hearing before a judge with physician and Hearing before a judge with physician and

patient present.patient present.• Must prove “Danger to self or others”or Must prove “Danger to self or others”or

meets the deterioration standard meets the deterioration standard • Can be committed UP TO 90 DAYS.Can be committed UP TO 90 DAYS.• May be discharged anytime staff believes May be discharged anytime staff believes

pt. is ready.pt. is ready.• Change to Out Patient commitment Change to Out Patient commitment

Extended Mental Health Extended Mental Health CommitmentCommitment

• Very strong evidence neededVery strong evidence needed• Commitment is up to 1 year.Commitment is up to 1 year.

• All commitments discussed can All commitments discussed can apply to Chemical Dependencyapply to Chemical Dependency

Assessment: Data Assessment: Data Collection Collection

• Legal Status: Back of chartLegal Status: Back of chart• Psychiatric Evaluation- 24 hoursPsychiatric Evaluation- 24 hours• Psychosocial Assessment- PSAPsychosocial Assessment- PSA• Psychological TestingPsychological Testing• Lab tests- the usual CBC, RPR.Lab tests- the usual CBC, RPR.

– Medication Levels: Lithium, Depakote, Medication Levels: Lithium, Depakote, TegretolTegretol

– Drug test on every patientDrug test on every patient

Mental Status Exam Mental Status Exam

• Appearance: Appearance: – Dress: Conservative, Desheveled, Dress: Conservative, Desheveled,

InappropriateInappropriate– Grooming: Clean, UnkemptGrooming: Clean, Unkempt– Facial expression: Alert, MasklikeFacial expression: Alert, Masklike– Eye contact: Does or doesn'tEye contact: Does or doesn't– Motor behavior: Mannerisms, Statue likeMotor behavior: Mannerisms, Statue like– Gait: Steady, StaggeringGait: Steady, Staggering– General Health: Well Nourished General Health: Well Nourished

MSE: SpeechMSE: Speech

• PacePace• Interruptions: steady flow, shuffling Interruptions: steady flow, shuffling • VolumeVolume• Clarity: Pressured, SlurredClarity: Pressured, Slurred• Tone and Modulation: Altered, Tone and Modulation: Altered,

calmcalm

Level of consciousnessLevel of consciousness

• Sensorium(Altered, Drowsy, Sensorium(Altered, Drowsy, Confused, Nonresponsive)Confused, Nonresponsive)

• General responsiveness to General responsiveness to environment (Distracted, able to environment (Distracted, able to sustain attention)sustain attention)

• Responds (Answers questions, Responds (Answers questions, follows simple instructions) follows simple instructions)

Emotional StateEmotional State

• Mood: Anxious, depressed, sad, Mood: Anxious, depressed, sad, calm, frightened, flat, angrycalm, frightened, flat, angry

• Affect: Intense. appropriate, labile, Affect: Intense. appropriate, labile, full range of emotionsfull range of emotions

Thought Process: FormThought Process: Form

• Autistic thinking: individualized Autistic thinking: individualized associations from with Patientassociations from with Patient

• Blocking: unconscious Blocking: unconscious interruptions in train of thoughtinterruptions in train of thought

• Circumstantial: digression of Circumstantial: digression of inappropriate thoughts into ideas inappropriate thoughts into ideas eventually reaching the desired eventually reaching the desired goalgoal

Thought Process: FormThought Process: Form

• Confabulation: unconcious filling of Confabulation: unconcious filling of gaps in memory with imagined or gaps in memory with imagined or untrue experiences that the person untrue experiences that the person believes but have no basis in realitybelieves but have no basis in reality

• Flight of ideas: Speech pattern is Flight of ideas: Speech pattern is rapid with no transition from topic rapid with no transition from topic to topicto topic

• FragmentationFragmentation

Thought Process: Form, Thought Process: Form, Cont.Cont.

• Loose associations: pattern of Loose associations: pattern of speech in which a person's ideas speech in which a person's ideas slip of track onto a topic that is slip of track onto a topic that is unrelatedunrelated

• Neologisms: New words created by Neologisms: New words created by the patientthe patient

• Perseverate: repetition of the same Perseverate: repetition of the same word or idea in response to word or idea in response to different questionsdifferent questions

• Tangential: inability to have goal-Tangential: inability to have goal-directed associations of thoughtsdirected associations of thoughts

• Word salad: incoherent mixture of Word salad: incoherent mixture of word or phrasesword or phrases

• EcholaliaEcholalia

Thought Content: ThemeThought Content: Theme

• Somatic symptomsSomatic symptoms• Rituals-Repetitive thinking or Rituals-Repetitive thinking or

behaviorbehavior• Destructive-Violence, suicide or Destructive-Violence, suicide or

HomicideHomicide• Defensive-Delusions, hallucinations, Defensive-Delusions, hallucinations,

distortions in perception, excessive distortions in perception, excessive ambivalenceambivalence

Cognitive FunctioningCognitive Functioning

• Oriented: Time, place person and Oriented: Time, place person and situationsituation

• Attention and concentrationAttention and concentration– Digit span exerciseDigit span exercise– simple arithmetic simple arithmetic

• Memory: Recent and RemoteMemory: Recent and Remote• General Intelligence: Name 2 presidentsGeneral Intelligence: Name 2 presidents

– days of the weekdays of the week

Cognitive Functioning, Cognitive Functioning, Cont.Cont.

• Abstract thinking: “A stitch in time Abstract thinking: “A stitch in time saves nine.”saves nine.”

What does this mean?What does this mean?Concrete thinking: “If it is torn you Concrete thinking: “If it is torn you

sew it up”sew it up”Abstract thinking: “If you take care Abstract thinking: “If you take care

of a problem right away it does not of a problem right away it does not get bigger”get bigger”

Cognitive Functioning, Cognitive Functioning, Cont.Cont.

• Insight and Insight and Judgment: Judgment:

• Is Patient safe?Is Patient safe?– Can ask problem Can ask problem

solving questionsolving question

• What would you do What would you do if a pipe broke in if a pipe broke in the house and the house and water was coming water was coming out?out?

• What would you do What would you do if you saw a small if you saw a small child on the end of child on the end of a dock by a lake?a dock by a lake?

Cognitive Functioning, Cognitive Functioning, ContCont

• Perceptions and Perceptions and Coordination: Coordination:

• Ask client to write Ask client to write name. name.

• Ask Client to draw Ask Client to draw a circlea circle

• Tests ability to Tests ability to follow a simple follow a simple command, fine command, fine motor skills, motor skills, ability to ability to assimilate and assimilate and transfer transfer informationinformation

Nursing AssessmentNursing Assessment

• How does pt. interact on unit?How does pt. interact on unit?• Does Pt. attend groups?Does Pt. attend groups?• Pt. have visitors, see Dr.. etc..Pt. have visitors, see Dr.. etc..• Employment history, marital statusEmployment history, marital status• Physical Assess; VS, Meds, Physical Assess; VS, Meds, • Sleep disturbanceSleep disturbance• Nutritional statusNutritional status• Physical illness/drug abusePhysical illness/drug abuse

Nurse Patient RelationshipNurse Patient Relationship

• Relationship is a partnershipRelationship is a partnership• Holistic View: treat body, mind, spiritHolistic View: treat body, mind, spirit• Emphasizes self-care and Emphasizes self-care and

responsibilityresponsibility• Individual seen in context of family Individual seen in context of family

and communityand community• THERAPEUTIC USE OF SELFTHERAPEUTIC USE OF SELF• 3 rules of psychotherapy 3 rules of psychotherapy

What is psychotherapy?What is psychotherapy?

• Modifies thoughts, feelings and Modifies thoughts, feelings and behavior in the context of a behavior in the context of a therapeutic relationshiptherapeutic relationship

• How is the Nurse Patient How is the Nurse Patient relationship different than a relationship different than a friendship? friendship?

3 Phases of Nurse Patient 3 Phases of Nurse Patient Relationship: OrientationRelationship: Orientation

• Time when Nurse and Patient introduce Time when Nurse and Patient introduce themselves and nurse defines limits and themselves and nurse defines limits and boundaries of the relationship. Make a boundaries of the relationship. Make a verbal contract.verbal contract.

• Confidentiality must be discussedConfidentiality must be discussed• Can not keep “secretsCan not keep “secrets””• Student Nurse examine own feelings; Student Nurse examine own feelings;

issues of self disclosure must be clear. issues of self disclosure must be clear. Goal is TRUSTGoal is TRUST

Working PhaseWorking Phase

• Pt. begins to share concerns with Pt. begins to share concerns with the nurse.the nurse.

• Pt. will talk about session before Pt. will talk about session before and tie it in.and tie it in.

• Phase may happen immediately or Phase may happen immediately or not at all.not at all.

Termination PhaseTermination Phase

• Patient and nurse review Patient and nurse review relationshiprelationship

• Often pt. feels free to share more.Often pt. feels free to share more.• Feelings: sad, relieved, angry, Feelings: sad, relieved, angry,

anxiousanxious• May ignore event altogether May ignore event altogether

Issues in the N/PT Issues in the N/PT RelationshipRelationship

• Transference: Phenomenon of Transference: Phenomenon of projection of thoughts, feelings, and projection of thoughts, feelings, and wishes onto the nurse who has come to wishes onto the nurse who has come to represent a figure from the patients represent a figure from the patients past.past.

• Occurs in all relationships.Occurs in all relationships.• Usually same sex parentUsually same sex parent• Overreactions of pts. usually Overreactions of pts. usually

transference.transference.

CountertransferenceCountertransference

• When Pt. represents someone from the When Pt. represents someone from the nurses past.nurses past.

• Identified by an overreaction on the Identified by an overreaction on the part of the nurse. part of the nurse.

• Can be a part of the self that nurse Can be a part of the self that nurse does not like. Example would be not does not like. Example would be not liking a patients indecision or liking a patients indecision or dependence.dependence.

• Alcoholism can cause strong feelings. Alcoholism can cause strong feelings.

Other FactorsOther Factors

• Countertransference issues are Countertransference issues are best dealt with by clinical best dealt with by clinical supervision.supervision.

• For students; tell instructorFor students; tell instructor• Rescue fantasy: Common response Rescue fantasy: Common response

of nursing and medical students. of nursing and medical students. Don’t expect too much of Don’t expect too much of yourselves or your patient.yourselves or your patient.

Effective HelpersEffective Helpers

• Empathy: Process that allows a person Empathy: Process that allows a person for that moment in time to really see for that moment in time to really see the situation from that persons’ the situation from that persons’ perspectiveperspective

• A healing momentA healing moment• Doesn’t include pity.Doesn’t include pity.• Sympathy: Assumption that your Sympathy: Assumption that your

situation parallels the pts. “I’m a situation parallels the pts. “I’m a mother, I understand”mother, I understand”

Review of Communication Review of Communication

• Which has more impact; verbal or non-Which has more impact; verbal or non-verbal communication. Body language.verbal communication. Body language.

• Describe the components of non-verbalDescribe the components of non-verbal• Nonverbal communication must be Nonverbal communication must be

verifiedverified• Advantages of open ended and close Advantages of open ended and close

ended questions. ended questions. • What is proxemicsWhat is proxemics

Common Mistakes: Making Common Mistakes: Making Assumptions, Crossing Assumptions, Crossing

BoundariesBoundaries• Patient states:”My child is getting Patient states:”My child is getting

on my nerves, sometimes I yell at on my nerves, sometimes I yell at him alot.”him alot.”

• Student: “I know what you mean. I Student: “I know what you mean. I yell at my children too. yell at my children too.

Conveying personal value Conveying personal value judgementsjudgements

• Pt. “My doctor says I’m going Pt. “My doctor says I’m going home tomorrow”home tomorrow”

• Student: “That’s great” Student: “That’s great”

Suggestive QuestionsSuggestive Questions

• Student: “Did you have a good Student: “Did you have a good time on your pass last weekend?”time on your pass last weekend?”

• Pt. “Yes”Pt. “Yes”

Avoid asking “why” Avoid asking “why”

• Your patient has made a suicide Your patient has made a suicide attempt by cutting his wrists very attempt by cutting his wrists very deeply. It is you first encounter. deeply. It is you first encounter. After introductions, the students After introductions, the students asks:asks:

• ““Why did you cut your wrists?”Why did you cut your wrists?”

Clarifies indefinite Clarifies indefinite pronouns pronouns

• Patient. “They are scaring me”Patient. “They are scaring me”

• Student. “There is nothing to worry Student. “There is nothing to worry about”about”

Concepts of Concepts of CommunicationCommunication

• Utilize your knowledge of the patients Utilize your knowledge of the patients illness when communicating.illness when communicating.

• Example: Manic patients need focusing Example: Manic patients need focusing questions, not open ended questions.questions, not open ended questions.

• Listen and respond to pts. StatementsListen and respond to pts. Statements• Example: “I don’t like being here at the Example: “I don’t like being here at the

hospital” St.“What is it you don’t like ?”hospital” St.“What is it you don’t like ?”• ““Here and now” better than past or Here and now” better than past or

future future