Introduction to Psychiatric Nursing Module 2: Concepts

1. Introduction to Psychiatric NursingModule 2: Concepts RNSG 2213

2. History Concepts • How were mentally ill treated prior to1790’s? • Banishment • Confinement • What were attitudes toward them? • Possessed by the devil • Lacked basic human qualities

3. St. Mary of Bethlehem Hospital, London (“Bedlam”) Opened to lunatics 1403 Visitors pay for “entertainment”

5. History Concepts • Period of Enlightenment begins in 1790’s • Concept of “ Asylum” (sanctuary): • If we treat patients humanely and respectfully, they will improve. • Mental illness worsens with stress • First mental hospitals (“asylums”) in US in 1820’s

6. History Concepts • Who was Dorthea Dix? • A nurse who was one of the first major reformers in the United States. • Helped develop the concept of an asylum • Direct role in opening 32 state hospitals

7. Dorthea Dix Asylum in North Carolina

8. Austin, Texas State Insane Asylum 1851

9. Medications first available in 1950s, i.e. chlorpromazine (Thorazine) for Schizophrenia, Lithium for Mania Hope for previously “incurable” mental illnesses and enhanced quality of life. Era of Psychotropic Drugs

10. Community Mental Health Movement • Response to the overcrowding and bureaucracy of public mental hospitals. • Chronically mentally ill “warehoused” and often abused, neglected • 1963 Community Mental Health Act • Concept: Patients can be treated better, cheaper in community • Massive deinstitutionalization: All State Hospitals in some states closed • Results: Increased acuity and strain on emergency services, increased number of homeless mentally ill

11. ETHICAL ASPECTS: SOCIAL VALUES(Consider what effect each of these values has on mental health care) • Individual Freedom • Money • Paternalism vs Libertarianism • Paternalism believes that an authority knows what is best for you • Libertarianism believes that the individual knows what is best for them • No other area of nursing is so affected by social values as psychiatric nursing

12. A Nurse Needs to Know About: • How to adapt legal principles to mental health settings: • safeguarding nursing practice from charges of negligence, false imprisonment, assault, or battery • DUTY TO WARN • Mental health professionals must warn others of a client’s threat of suicide or of harm to self or others

13. Rights of Psychiatric/Mental Health Patients • Right to refuse treatment • Right to informed consent ( and the right to know about rights) • Right to confidentiality • Right to receive visitors and telephone calls • Right to be treated with respect • Right to be treated in the least restrictive environment

14. Client Rights • Concept of Least Restrictive Environment: • Should guide nursing decisions • Seclusion is used when the person is a danger to others • Restraint is used when the person is a danger to self • Never used to get a patient to comply

15. Rights of Mentally Ill Patients • Basic Needs: • Warmth: clothing a blanket • Food • Access to the outdoors • Contact with family, legal representative • Do NOT have right to all possessions (When can access to possessions be restricted?)

16. Legal Aspects: Commitments(As Applied under Texas Law) • Mental illness as defined by the Texas Mental Health Code • “Mental illness is a disease or condition which either: • Substantially impairs the person’s thought, perception of reality, emotional process and/or • Grossly impairs behavior as manifested by a recent event of disturbed behavior (“Gravely disabled”)

17. Commitments Voluntary Commitment • A person 16 years of age or over signs themselves in for admission. Person is advised of their rights under the code. • 4 Hour Rule: If a patient changes their mind about being in the hospital, psychiatrist has 4 hours to file for a commitment. • Signs a consent for treatment.

18. Commitments, cont’d • Most commitments are voluntary where the individual or the therapist request admission and the patient meets criteria for admission • The patient must sign consents for all psychotropic medications. Refusal to sign these consents means the medications can NOT be administered

19. Involuntary Commitments Emergency Mental Illness Commitment Allows Mental Health Deputies (CrisisIntervention Team) to pick up a person who presents an “IMMINENT DANGER TO SELF OR OTHERS” and is “Gravely Disabled” and bring them into custody for 24 HOURS. • MD can begin commitment procedures (file) at that time.

20. Involuntary Commitments, cont’d Order of Protective Custody (OPC) • Commitment must be accompanied by a medical certificate, which states that the physician has examined the patient within 24 hours. Filed at the County Clerk’s Office. • Probable Cause Hearing within 72 hrs. • Pt. can be committed for 14 days.

21. Involuntary Commitments, cont’d Temporary Commitment • Papers must be filed with the Court • Hearing before a judge with physician and patient present. • Must prove “Danger to self or others” or meets the deterioration standard • Can be committed UP TO 90 DAYS. • May be discharged any time staff believes pt. is ready. • May change to Outpatient Commitment

22. Involuntary Commitments, cont’d Extended Mental Health Commitment • Very strong evidence needed • Commitment is up to 1 year.

23. Last but not least . . . . • All involuntary commitments can include court-ordered medications • All commitments discussed previously can apply to Chemical Dependency

24. TREATMENT SETTINGS AND THE CONTINUUM OF CARE • Where do we see the mentally ill being treated? • How do individuals enter the mental health system? • Why is discharge planning so important?

25. PSYCHOTHERAPEUTIC MANAGEMENT • TOOLS ARE: SELF  DRUGS  ENVIRONMENT  Therapeutic Use of SELF (Nurse-Client Relationship)  DRUGS: Psychopharmacology  ENVIRONMENT: Therapeutic Milieu

26. NURSE ON THE MENTAL HEALTH TEAM • Mental Health Team: • Psychiatrist • Nursing staff: includes licensed nurse, tech • Psychiatric Social Worker • Psychologist • Therapeutic Recreation and Expressive Arts personnel • Client and Family • Other: Substance abuse counselor, employment specialist, dietician, etc.