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208 Cards in this Set
- Front
- Back
- 3rd side (hint)
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3 Specific Admisions
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1. Voluntary
2. Involuntary 3. Noncontested |
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2 typs of Voluntary admits
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1. Formal
2. Informal |
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Info about Formal
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1. Pt has to make an application for admit
2. must apply 72 hrs before leaving |
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Info about Informal Admit
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Pt can request immediate discharge
1. during business hours or has to wait for the next day 2. can leave immediately but must sign AMA (against medical advice) |
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3 types of Involuntary admits
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1. OPC - Order for Protective custody
2. Physician's Emergency Certificate (PEC) 3. Judicial Committment |
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OPC
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issued by Coroner or judge, by family member or other who claims ind. will hurt themselves or others. Police can pick them up but must take them to a facility within 72 hrs, then they must be seen within 12 hrs by a MD
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PEC
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a La. licensed MD can write a PEC if pt is believed to be harmful to themselves or others. and cannot follow the Formal Voluntary Admi procedure. Within 72 hrs a deputy psychiatrist from the Coroner will examine the pt. If both have the same opinion then the pt's status changes from PEC to a CEC. may be detained in hospital for 15 days
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CEC
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when the coroner's psychitrist agrees to the admit on a pt., a CEC is issued and takes place of PEC. Pt. can be held for mental for 15 days
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Judicial Commitment
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when the CEC runs out, the pt's family can file a petition in civil court. within 18 days a judge must decide that the pt must stay until released by a physician
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Noncontested admit
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an organic mentally ill pt who just cannot give permission one way or the other is admitted. The purpose is a Complete diagnostic eval, which must be completed within 14 days. cannot be held more than 3 mths
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Emergency Admit
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pt acts in a way that indicates that they are mentally ill and because of the illness, likely to harm themselves or other. All enter for the purpose of diag., eval. and emer. trmt
the pts right to come and go is restricted, they may be forced to take meds, ECT is not allowed unless ordered by the court or legal guardian. allowed an attorney |
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Cultural congruence
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pts receive an overall message, conveyed both verbally and non-verbally, of personal and cultural validation.
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Cultural competence
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include: CA + CK + CS + CE
CA= C.Awarness CK= C.Knowledge CS= C.Skills CE= C. Encounter having the skills, academically and interpersonally, to understand and appreciate cultural diff. and similarities within, btw and among groups |
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Assimilation
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the expectation for immigrants and minority groups to become like the majority culture.
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Ethnocentrism
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the belief that one's own cultural practices and values are inherently correct or superior to those of other
include Prejudice, Stereotypine, Discrimination, Stigmatization |
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reuptake
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when neurotransmitters are returned back into the neuron
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second hit
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interaction btw genes & environment: explains how twins can be different. When things like abuse, neglect, infections or prenatal exposure to alchohol can effect the brain and cause problems.
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Behavior therapy
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principles of operant conditioning & conditioned reflex
treats: anxiety, sexual disorders,PTSD, Addictions need Baseline to be able to measure find correct reinforcer |
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Using Conditioning
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Strengthening through reinforcement
Timing of Reinforcement is critical Premack Principle- earn your privledges-such as TV |
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Schedules of Reinforcement
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1. Continous-after ea behav.
2. Intermittent- after set amt ex: after every 5th occurrence |
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Decreasing the probablilty that a behavior will occur
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1.Differential reinforcement
only pay attention to good behav. 2.Extinction- gradual decrease in rate of response when reinf. is no longer available 3.Negative consequence- immediately react 4. Time Out 5. Response cost- negative conseqen. pt removed physically |
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Skills Training
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new behav. are taught via social skills training & problem solving-positive reinf. & modeling
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Continguency contracting
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pt & therapist agree on behavior change and reinforcers
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Self Control
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assess, change, reinforce, evaluate- ex: rubberband for compulsions
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Token economy
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earn tokens
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Respondent conditioning
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self talk, yoga, deep breathing , meditation, imagery
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systematic desensitization
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progressive exposure to stimuli that causes anxiety
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The Nsg Process & behavioral interventions
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1.assessment of beh. & related contingencies
2. behavioral nursing diag. 3. outcome id, planning & implementation of program 4. evaluation of results |
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Guidlines for behavoral nsg intervention
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Baseline observation:
type of behavior id the inappropriate beh. determine absent age-appr. beh |
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Problem specifications (Nsg dx)
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select response to be changed
define response so that everyone can recognize it gather baseline data |
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NSG responsibilities per ECT
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1. consent signed
2. NPO -6-8 hrs 3. Atropine w/in 1 hr of trmt 4. urinate 5. remove items from body 6. take VS 7. nurse remain positive & < anxiety 8. insert IV line 9. attache elect. to head, held in place w/ rubber band 10. insert bite block 11 give meds |
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Meds for ECT
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Methohexital (brevital)-immediate anesthesia
Succinylcholine- prevents the ext. manifestations of a grand mall seizure |
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NSG post- ECT
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1.02 at 100%
2. monitor for resp. problems 3. reorient 4. admin benzodiazepine for agititaion 5. assisst w/1st attempt at standing 6. doc |
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How many trmt?
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2-3 per week for 6-12 trmts
relief after 2-3 rx for depressed people |
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Contraindicaiton for ECT
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if have: recent MI, recent cerebrovascular accident
angina, CHF, loose teeth, pulmonary dis. osteoporosis, bone fx, glaucoma, retinal detachment, thrombophlebitis, pregnancy |
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problems with ECT
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hypertension, arrhythmia
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Psychosurgery for:
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depression/anxiety
depression related pain OCD aggression |
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Phototherapy
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SAD, Bulimia, Insomnia, nonseasonal depression
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Transcranial Magnetic Stim
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no anesthesia, se: seizures, headache, hearing loss,
for: depression, mania, schizophrenia |
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Patient risk factors for anger
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-head trauma
-psychiatric illness -substance abuse -young males -prior hist |
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Anger is?
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a response to feeling threatened, scared or hurt
look for "safe target" |
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What to do as a nurse with angry pts, family, visitors?
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listen, reframe, emphasize, consult social worker/psy. sometimes stop when another person with percieved power shows up
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Top prevent: communicate the process
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1. identify yourself & role
2. anticipate their questions 3. explain the process & procedures 4. acknowledge their emotional pain, 5. empathize |
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Phase issues based on purpose
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safety and healthcare issues and not laws
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Tips: verbal strategies
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1. listen
2. set limits 3. restate common goals |
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Mental illness is?
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a lack of harmony with aspects of living
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DSM-IV:
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Axis I-V
Emotional personalities have medical & psychosocial problems, globally |
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Axis I
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emotional disorders, diagnosis of mental illness
Anxiety, childhood disorders, cognitive disorders, eating disorders, substance abuse, depression, etc |
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Axis II
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personality disorders and mental retardation
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Antisocial Personality Disorder
Avoidant Personality Disorder Borderline Personality Disorder Dependent Personality Disorder Histrionic Personality Disorder Narcissistic Personality Disorder Obsessive-Compulsive Personality Disorder Paranoid Personality Disorder Schizoid Personality Disorder Schizotypal Personality Disorde |
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Axis III
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medical problems
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General Medical Conditions is for reporting current medical conditions that are potentially relevant to the understanding or management of the individual's mental disorder. The purpose of distinguishing General Medical Conditions is to encourage thoroughness in evaluation and to enhance communication among health care providers. General Medical Conditions can be related to mental disorders in a variety of ways. First, it is clear the medical condition is directly related to the development or worsening of the symptoms of the mental disorder. Second, the relationship between the medical condition and mental disorder symptoms is insufficient. Third, there are situations in which the medical condition is important to the overall understanding or treatment of the mental disorder
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Axis IV
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Psychosocial & Environmental problems-affecting behaviors
2nd steps |
Primary Support Group
Problems Related to the Social Environment Educational Problems Occupational Problems Housing Problems Economic Problems Problems with Access to Health Care Services Problems Related to Interaction with the Legal System/Crime Other Psychosocial and Environmental Problems |
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Axis V
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global assessment functioning-best level of psycobiological, societal, occupational functioning over the past year
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Scale from 0 -100 getting better as go up
Global Assessment of Functioning is for reporting the clinician's judgment of the individual's overall level of functioning. This information is useful in planning treatment and measuring its impact, and in predicting outcome. |
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Major Biological Influences on Mental Health
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genes, infections, physical trauma, nutrition, hormones, & toxins
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What are the executive functions of the brain?
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insight,
planning solving problems regulating behaviors |
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Table pg 23, Biogenic Amines, Catecholamines
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Dopamine-pleasure-schizophrenia
norepinephrine-awareness-mood disorders epinephrine-limited presence in brain- fight or flight response |
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Biogenic Amines: Indolamines
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1. Serotonin- temp regulations- decreases depression, increases anxiety
2. histamine- allergic response, wgt gain assoc. with psy. meds |
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Biogenic Amines: Cholinergics
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1. Acetylcholine: cognitive func. or modulating neurotransmitters directly - most wildly used neurotran. -decreases Alzheimers
2. Neuropeptides: endorphines play 2nd messenger role & pain response- |
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Amino Acids
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implicated in dementia, schizophrenia, and anxiety
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Meds act differ. on diff. cultures
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Asian amer. slow metabolizer of antipsychotic & antidepressants- more s.e.
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Psychosocial influences
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parents, socioeconomic status, racial, cultural and religious backgound and interpersonal relationships
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Primary psychosocial influencer
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poverty
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Culture: Assessment
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gather data from nurses, to view the pt in the contexts (culture) in which he exists
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Six cultural phenomena
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communication
space social organizations time enviromental control biological variation |
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3 major belief systems
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1. biomedical (US)
2. Personalistic-spirtiual world 3. Naturalistic -result of disequilibrium |
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Hispanic culures
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1. present time not future
2. less personal space 3. male authority 4. health is good luck or gift from god 5. home remedies, folk health 6. less than 1 in 11 seek help 7. immigrants fewer than 1 in 20 seek healp 8. suicide rate low 9. many suffer from PTSD |
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Asian Culture
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1. balance of two opposite forces
2. father is authority figure 3. Mds and nurses are respected have restraint in behavior little substance abuse PTSD high in refugees |
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African American Culture
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1. matriachal
2. family and comm. strong 3. time is flexible 4. close personal space 5. direct connection btw health and god 6.medical and spiritual 7. reluctant to give health info 8. frequent drama in behav. |
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Middle Eastern Culture
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1. women do not see md's alone
2. husband remains in room 3. husband is the family leader-women cannot sign consent 4. must establish trust-family history is private 5. stoic & dutiful behavior |
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cross cultural understanding
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why people of culture respond in a specific way - ask if u do not understand
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Facilitation skills
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resolve difference btw health care system expectations and pt needs
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Flexibility
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able to recognize when changes need to be made
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Indicators of mental health include:
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positive attitudes toward self, growth & developmental levels, ability to achieve self-actualization, integration of self, autonomy, perception of reality, & mastery of environment
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Hildegard Peplau
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published Interpersonal Relations in Nursing
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ANA definition of mental health nursing
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specialized area of nursing practice employing theories of human behavior as its science & purposeful use of self as its art
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Mental Health Nursing is
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interpersonal process that promotes & maintains pt behaviors that contribute to integrated functioning. The pt's goals are met through nurse pt relationship that enable pt to adapt to stress as a unique individual. Nurses work with individuals, families, groups, organizations & communities
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START OF
Professional Aspects of Psychosocial Nursing I & II |
START OF
Professional Aspects of Psychosocial Nursing I & II (These lecture notes are for Intro, Legal Aspects, Nurse-Patient Relationship.) |
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MENTAL HEALTH
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Subjective meaning that changes with cultural/social norms & varies at different times of life depending upon growth & developmental tasks, stresses etc.
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Indicators of mental health
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positive attitudes toward self, growth & developmental levels, ability to achieve self-actualization, integration of self, autonomy, perception of reality, & mastery of environment.
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MENTAL ILLNESS
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An estimated 22.1 percent of Americans ages 18 & older—about 1 in 5 adults—suffer from a diagnosable mental disorder in a given year. When applied to the 1998 U.S. Census residential population estimate, this figure translates to 44.3 million people. In addition, 4 of the 10 leading causes of disability in the U.S. & other developed countries are mental disorders—major depression, bipolar disorder, schizophrenia, & obsessive-compulsive disorder. (NIMH)
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(In the Past) mental health
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Previously mentally ill were locked away, hidden, blamed, etc. No medications until 1950. Treatment was long term & limited to physical restraints, insulin, brain surgery, electroconvulsive (ECT) therapy.
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Current treatments
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-mainly medications
-are more effective in controlling symptoms of the various illnesses -Today, still do ECT |
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Selected Historical Developments of Mental Health Nursing
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-1946 National Institute of Mental Health was formed providing funds for psychiatric nursing education.
-1950 National League for Nursing required that schools of nursing must include in psychiatric nursing in educational programs. -1953- Hildegard Peplau published Interpersonal Relations in Nursing -1963 Community MH Center Act passed, moving treatment from hospitals into out patient care. Focus shifted to preventive care. -1973 - Standards of practice for psychiatric nursing were developed & certification for psychiatric mental health nurses began -2002- commission developed to reduce disparity in mental health care & improve the coordination & quality of services of the nation's mental health service delivery system. |
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ANA definition of mental health nursing:
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Specialized area of nursing practice employing theories of human behavior as its science & purposeful use of self as its art
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What is used to base Mental Health Nursing practice?
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Knowledge from psychosocial & biophysical sciences & theories of personality & human behavior
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What is Mental Health Nursing?
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an interpersonal process that promotes & maintains patient behaviors that contribute to integrated functioning. The patient’s goals are met through nurse patient relationship that enable patient to adapt to stress as a unique individual. Nurses work with individuals, families, groups, organizations & communities
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Goals of Therapeutic Nurse Patient Relationship
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- Help patient to achieve self- realization, self-acceptance, & increased genuine self-respect
- Develop a clear sense of personal identity & improved level of personal integration -Become able to form intimate, interdependent, interpersonal relationships with the capacity to give & receive love -Improve functioning & become able to satisfy needs & achieve realistic personal goals |
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Helping Patients Achieve Goals
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Nurses work in therapeutic partnership with others to help them achieve their goals through the nurse’s therapeutic use of self. Nurse must be able to communicate in open & personal way to assist other person to meet needs
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Client's needs are met by:
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- Encouraging person to express thoughts & feelings related to behaviors & clarify areas of conflict & anxiety.
- Assisting in identifying & maximizing person’s strengths & encouraging development of relationships. - Improving communication with others & helping to modify maladaptive behavior patterns - Developing an awareness of self as worthwhile person |
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Developing Self- Awareness
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In order to develop self- awareness, person needs to develop an understanding of all aspects of self
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Areas that need to be understood to develop self-awareness are:
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-Psychological component
-Physical Component -Environmental Component -Philosophical Component |
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Self- Awareness: Psychological component
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Must develop knowledge of own emotions, motivations, self-concept & personality by becoming sensitive to own feelings & to external elements that affect these feelings.
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Self- Awareness: Physical Component
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-Having knowledge of own personal & general physiology & how body responds physically.
-Developing an awareness of own body image -Recognizing physical abilities & potential of physical ability. -Recognizing bodily sensations & responses of body to physical aspects. |
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Self- Awareness: Environmental Component
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All areas of socio-cultural environment that person lives in including the person’s relationships with others, knowledge of relationships between humans & nature of these relationships.
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Self- Awareness: Philosophical Component
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-Understanding the philosophical component of self so that a sense of life as having meaning.
-Developing a personal philosophy of life & death. -Having personal accountability & feeling a sense of responsibility to others. -Developing a personal code of ethics of behavior & having increased self-awareness of these. |
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Philosophical Component (Johari’s Window)
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Represents person’s total self
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Johari’s Window
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SEE Diagram in Notes
- A change in any one of the 4 quadrants of Johari’s window affects all quadrants. -The smaller that quadrant one is (area known to self & others) the poorer communication with others is. When self-awareness is improved, interpersonal learning has occurred so that change has taken place. Quadrant 1 becomes larger & one or more of other quadrants is smaller. |
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Johari’s Window - Quadrant 1
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includes behaviors, feelings & thoughts known both to self & to others
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Johari’s Window - Quadrant 2
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includes all the things that an individual does not know about self but is known to others
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Johari’s Window - Quadrant 3
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includes things that only the person knows about them self
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Johari’s Window - Quadrant 4
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includes things that are not revealed to self or others
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Johari’s Window - Steps in Increasing Self-Knowledge of Area Known to Self & Others
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To enlarge quadrant 1, you must listen to self & be able to experience genuine emotions, identify & accept personal needs & move body comfortably. Explore personal thoughts, feelings, memories & impulses.
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Johari’s Window - Steps in Increasing Knowledge of Area Known to Others
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Requires active listening & being open to feedback of others. Listen to & learn from others. As you relate to others, you broaden perceptions of self.
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Johari’s Window - Increasing Area Known Only to Self
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Must be willing to self-disclose or reveal to others important aspects of self. This is a sign of personal health & a means of achieving healthy personality.
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Expectations of Nursing Students Related to Developing Self-Awareness
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- Self-analysis by clarifying your values
- Accept & respect individual’s differences & limitations - Engage in self-exploration to increase functioning, self-direction & become open in exploring feelings, needs, problems, emotions, communication & goals |
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Diagnosis of Mental Illness- DSM-IV-TR
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-Describes behaviors or psychological patterns exhibited that are associated with distress or disability.
-Classifies mental health disorders & provides guidelines & diagnostic criteria. -Assesses 5 dimensions that influence the individual. |
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(Axis of DSM-IV-TR) Axis I
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Signs & symptoms of psychiatric disorder, primary diagnosis & other conditions requiring attention
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(Axis of DSM-IV-TR) Axis II
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Long term patterns of behavior &/or mental retardation
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(Axis of DSM-IV-TR) Axis III
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General medical conditions
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(Axis of DSM-IV-TR) Axis IV
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Psychosocial & environmental problems affecting diagnosis, treatment, & prognosis
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(Axis of DSM-IV-TR) Axis V
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Global Assessment Functioning (GAF) Level of psychological, social & occupational functioning on scale of 1-100
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Socio-Cultural Factors of Mental Health & Illness
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-These influence the amount & type of coping resources available.
-Distress is expressed by different cultures in various ways. -This influences ways symptoms of mental illness are expressed. -In some cultures a particular behavior may be considered normal or accepted whereas it may not be normal or accepted in others. -Socio-cultural factors may also influence the person’s vulnerability to, development of & recovery from psychiatric disorders. It may determine what & if treatment is acceptable. |
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Socio-Cultural Factors (Mental Health & Illness)
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-Socio-Cultural Risk Factors
-Age -Ethnicity -Gender -Educational Levels -Income Levels -Belief System (Religion, Spirituality, Value System) -Socio-cultural Stressors -Mental Health Care |
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Socio-Cultural Risk Factors
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-There may be an increased potential for developing a disorder.
-This is not a cause of the illness. -There may be a decreased potential for recovery based upon acceptability of treatment. -This includes social norms, cultural beliefs, & personal values of person. |
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Age
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Studies have shown that seeking mental health treatment decreases with age, peaking between 25-44 years old.
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Ethnicity
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-Refers to racial, national, or cultural origin or background of person.
-The prevalence of disorders varies in ethnic groups. -African Americans tend to be diagnosed more with schizophrenia & with affective disorders least. -The use of mental health services also varies with ethnic groups. -African Americans, Native Americans, Hispanics & Asians generally utilize state & public hospitals instead of community & private agencies. -Type of treatment & medications utilized varies |
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Gender
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-The prevalence of mental illness is equal among men & women, but the type of disorder diagnosed differs between men & women.
-Substance abuse & antisocial personality disorders are diagnosed more frequently among males. -Men tend to externalize feelings. -Anxiety & affective disorders are diagnosed more frequently among women who tend to internalize feelings. -Women also tend to develop illnesses earlier than men do. |
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Educational Levels
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Education is more important than income in determining the use of mental health services. Those with higher educational level tend to use mental health services more.
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Income Levels
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-Poverty has an extreme effect on mental health.
-Women, elders & ethnic minorities have greater levels of poverty. -They experience numerous stresses on daily ongoing basis. -This also influences the person’s diet, treatment, lead exposure, exposure to violence, drugs, etc. |
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Belief System (Religion, Spirituality, Value System)
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-We need to make sense of life experiences.
-A healthy adaptive belief system will enhance person’s sense of well being. -This can improve quality of life & speed recovery (i.e. some religions avoid alcohol). -Compatibility between patient & provider’s beliefs may improve acceptance of the treatment recommendations & compliance with treatment. |
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Socio-cultural Stressors
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-Disadvantaged people have a lack of resources
-Stereotyping refers to the concept of having expectation of an individual due to their socio-cultural status. -This can lead to behaving toward others in a depersonalized way. -Stigma refers to a trait that is considered unfavorable. -Discrimination involves different treatment of person or group of people due to socio-cultural status. |
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Stereotyping
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refers to the concept of having expectation of an individual due to their socio-cultural status. This can lead to behaving toward others in a depersonalized way.
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Stigma
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refers to a trait that is considered unfavorable.
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Discrimination
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involves different treatment of person or group of people due to socio-cultural status.
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Mental Health Care
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-Treatment of mental illness involves balancing rights of society as a whole versus rights of the individual.
-The amount & type of care varies with the needs of an individual at any particular point in time. -There is a continuum of care from least restrictive environment to provision of maximum level treatment & care. -Access to treatment varies depending on financial, legal & ethical factors |
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Primary Level of Prevention of Mental Illness
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Altering factors that can lead to illness, promote health factors, protect against disease by:
-Educating people about areas such as growth/development & abuse. -Identifying areas of stress & how to modify it. -Identifying community factors impacting individuals & families. -Supporting individuals & families & referring them for help before crisis arises. -Settings include individual as well as group & community areas |
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Secondary Level of Prevention of Mental Illness (Acute Phase of Illness)
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ACUTE.
Reducing illness by early detection & treatment by: -Screenings (i.e. depression, alcoholism) -Hospitalization -Crisis intervention -Suicide prevention -Treatment focus is to relieve symptoms with goal to stabilize a person at risk for physical or emotional deterioration due to active psychiatric or substance abuse condition. -Settings: inpatient hospital, residential facility, detoxification units, respite care. Person would not be safe at less intensive level of care |
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Tertiary Level of Prevention of Mental Illness (Recovery, Rehab, or Maintenance Phase)
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CHRONIC.
Reducing damage of illness to achieve optimum level of functioning by providing treatment in community settings by: -Promoting training & rehabilitation of mentally ill (achieved by completing formal education, job training, employment assistance, & housing) -Assisting in transition from hospital to community with support services providing a supportive environment to improve coping & interactions in structured settings with individuals or groups -Therapeutic intervention to maintain functioning at optimum level by monitoring the effectiveness of medications & treatments -Providing education regarding health issues -Intervening with family & other support systems -Providing respite care -Settings: partial hospital, day treatment, group homes, outpatient mental health clinics |
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Admission in Louisiana:
Voluntary |
- Formal Voluntary (FVA)
- Informal Voluntary Admission in Louisiana |
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Formal Voluntary (FVA)
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-most common type of admission for treatment
-Patient signs self into facility requesting treatment. -Patient agrees to give staff 72 hour notice requesting release if desires to be discharged. -Patient retains right to accept or reject any treatment recommendations by staff (medication, etc.) -If person desires to be discharged, requests & signs a 72-hour request for release. -Psychiatrist must determine if person meets criteria for commitment, if so they cannot be released. |
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Informal Voluntary Admission in Louisiana
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-Patient requests admission & signs self into facility for treatment.
-Patient does not have to give 72-hour request for release. -Patient retains right to accept or reject any treatment recommendations by staff (medication etc.) |
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Non-Contested Admission in Louisiana
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-Infrequently used, generally if person is unable to legally sign self in for voluntary treatment, but is not in disagreement with admission (i.e. intoxicated, uncommunicative etc.)
-Patient retains rights to agree or reject any treatments |
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Order of Protective Custody
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-Used when a person is unwilling or unable to seek treatment on his or her own.
-In La. must get an order of protective custody from coroner’s office. -Family or other party must initiate legal proceedings to have person picked up by the police for own safety or safety of others -Person is transported by police to a hospital for evaluation; this doesn’t guarantee that the person will be admitted. |
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Involuntary Treatment
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Criteria for Commitment to treatment when a person is:
-Danger to self -Danger to others -Unwilling to seek treatment -Unable to seek treatment -under the influence of drugs or alcohol |
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Types of Commitments
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-Physician’s Emergency Certificate (PEC)
-Coroner’s Emergency Commitment (CEC) -Judicial Commitment for Treatment |
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Physician’s Emergency Certificate (PEC)
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-Physician must conduct examine in person
-Evaluates mental status to determine need for treatment & ability to be treated on voluntary basis. -If cannot or will not sign in voluntarily & meets criteria, then will be committed PEC for 72 hours. -This commitment allows staff to make decisions about treatment. -Medications can be given without patient’s agreement. |
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Coroner’s Emergency Commitment (CEC)
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-When person is admitted with PEC, coroner’s office is notified. Psychiatrist from coroner’s office must examine patient within 72 hours
-If patient remains unable or unwilling to sign voluntary admission certificate, & coroner’s psychiatrist decides patient meets criteria for commitment, will sign CEC -This commits person to remain hospitalized for treatment for 15 days -On a PEC or CEC, patient can sign self into hospital for treatment on voluntary basis. |
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Judicial Commitment for Treatment
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-After CEC expires, if more treatment needed & patient is unwilling or unable to sign consent for treatment (FVA) psychiatrist must initiate legal steps for judicial commitment.
-Once this process starts patient continues treatment until legal hearing occurs & judge hears evidence from both patient & psychiatrist regarding need for further treatment. -Patient has right to hire independent psychiatrist to examine & testify. |
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In-patient Status of Patients
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A. Strict Visual Contact (SVC) constant visual contact
B. Modified Visual Contact (MVC) C. Close Observation (CO) |
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PATIENT’S BILL OF RIGHTS
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-1973: American Hospital Association issued these & many hospitals adopted them
-1990: Reaffirmed -Rights vary from state to state, however generally psychiatric patient does not lose any civil rights even if involuntarily committed for treatment |
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PATIENT’S BILL OF RIGHTS
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- Right to Informed Consent
- Right to Communicate - Right to Keep Personal Effects - Right to Execute Will - Right to Enter Contractual Relationships - Right to Education - Right to Habeas Corpus - Right to Independent Psychiatric Exam - Right to Privacy - Right to Confidentiality - Right of Privileged Communication (Testimonial Privilege) - Right to Treatment - Right to Treatment in Least Restrictive Setting |
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Right to Informed Consent
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-Patient must be given information about treatment, complications, options for any alternative treatments & prognosis expected with treatments or without treatment.
-Patient has right to accept or refuse as long as they have voluntarily requested treatment. -May not be best choice but patient has legal right to make the choice as long as they have not been declared incompetent. -Living Will, Medical Power of Attorney, & Advanced Directives are important so that person can make wishes known. |
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Right to Communicate
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Patient has right to:
-Visit with others privately (can be supervised). -Reasonable access to private telephone conversations -Send & receive unopened mail -Visits can be limited to specific times & may be supervised. -Can only be restricted or suspended for treatment reasons (i.e. harassment, substance abuse). -Patient has right to seek own mental health professional for other opinion or treatment. -ALWAYS HAS RIGHT TO COMMUNICATE WITH ATTORNEY! |
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Right to Keep Personal Effects
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-Patient has right to bring clothing & personal objects to hospital.
-Staff is responsible for maintaining a safe environment & dangerous items may be removed. -Facility is not responsible for any items person brings to facility. |
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Right to Execute Will
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Conditions that must be met in order for a will to be considered valid:
-Person must know they are making a will -Person must know nature & extent of property they own. -Does not mean must know all details of property but can’t give away things don’t own -Person must know who friends & family members are & what these relationships mean (Do not have to leave them anything) -For a will to be valid, person must not be mentally confused at time will was made. -Will made during a lucid period remains valid as long as person meets criteria when will was made. -Nurses may be involved & witness will & may have to testify as to competency. -Nurse’s charting may be used in court to verify patient’s mental status. |
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Right to Enter Contractual Relationships
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-Patient has right to make decisions about contracts
-These contracts are valid as long as person understands circumstances of contract & consequences. -As long as person is competent when making the contract, it is valid even if person became incompetent later |
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Right to Education
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-Constitution of U. S. guarantees right to all.
-Children receiving treatment must be provided with education. |
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Right to Habeas Corpus
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-A committed person can file this at any time on grounds of being sane & eligible for release.
-A hearing must be held & if patient is determined to be sane must be immediately released. -The goal is speedy release of any person being detained illegally |
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Right to Independent Psychiatric Exam
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-Patient has right to be examined by physician of choice. Patient must pay for this exam.
-If this physician determines that patient is not mentally ill, patient must be released |
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Right to Privacy
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-This involves confidentiality to prevent information from being revealed.
-This has become more important than ever with HIPPA. -It involves even acknowledgment that person is a patient in the facility (cannot give this information over telephone or in person) -Written consent is needed to provide ANY information. -This can become a major issue with patient trust if they are to disclose any information in therapy situations. |
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Right to Confidentiality
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-Only those with need to know information may be given this.
-Patient can reveal any information to anyone of his or her choice. -Exceptions occur in certain cases where abuse or other legal situations arise |
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Right of Privileged Communication (Testimonial Privilege)
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-This right applies only to court related proceeding.
-It includes communication between husband/wife, attorney/client, clergy/church member, doctor/patient. -Some states have extended this to other health care workers who has communication of professional nature |
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Right to Treatment
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-This applies to involuntary or committed patients as minimum standards as well as to voluntary.
-Person has right to humane psychological & physical environment. -They have right to treatment free of discrimination, right to treatment with dignity & respect. -Qualified staff with sufficient number to administer adequate treatment must be provided. -Person must have an individualized treatment plan -Refusal of medications has become a major issue & lawsuits have increased. -Nurses are faced with challenge of wanting to help patient versus patient’s right to decide. -Experimental treatment requires consent & knowledge of consequences of the experiments. |
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Right to Treatment in Least Restrictive Setting
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-Maintaining greatest amount of personal freedom, autonomy, dignity, & integrity in determining treatment is goal.
-Applies to when person should be hospitalized & how person should be treated. -Patient’s progress must be monitored so that treatment plans are changed based on condition & patient must be involved in planning with discharge plans identified |
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Other Rights of Patients
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- Patient has right to religious freedom to practice religion & observe religious customs.
- Patient has right to make purchases - Patient has right to retain or achieve civil service status - Patient has right to sue or be sued |
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Structural Limitations of Treatment
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-Type of treatment setting must be considered, i.e. is hospitalization necessary?
-Limitations of physical freedom including seclusion & restrictions must be justified for treatment reasons or safety of person or others. -Any limits on freedom must be therapeutically indicated & justified. -Legal requirements to follow regarding restraints include determination of when to use, physician’s orders for these, length of time for restraints etc. -Policies of facility must be followed. -This is closely related to right to adequate treatment -This applies also to rules, procedures, routines & regulations for operating the agency & degree of patient involvement in planning. -Consequences of patient breaking rules must be defined (i.e. discharge from treatment) |
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Other Aspects of Treatment in Least Restrictive Setting
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-Treatment involving the use of medications & other somatic treatments such as ECT.
-Psychosocial atmosphere of facility also involved here such as the degree of authoritarianism of staff & differences between patients (i.e. level of patient privileges). -Patient characteristics must be considered such as patient’s ability to manage care & level of functioning as influenced by severity of disorder |
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Mental Health Advocacy Service
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-Protection & Advocacy Act for Mentally Ill Individuals Act of 1968 established agency to ensure patient’s rights are protected.
-NLN defined nurse’s role identifying respect & concern for patients & competent care as basic rights along with patient’s receiving necessary information to understand their illness & make decisions about their care |
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Forensic Issues
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Number of mentally ill in prison increased over past 30 years due to lack of long term treatment facilities & support services in community.
-This is especially true with juveniles |
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Incompetency versus Incapacity
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Incompetency versus Incapacity
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Competency
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-is a legal determination to protect person from inability to understand & transact business
-Psychiatrist does not determine this, but psychiatrist may be asked to evaluate mental status. -To be declared legally incompetent, a mental disorder must be diagnosed. -The mental disorder causes impairment in judgment. -The impaired judgment leaves the person incapable of handling personal affairs |
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Incapacity
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-means the person is unable or incapable to complete or fulfill role or obligation.
-This is not a legal determination. -This may be temporary condition due to either physical or mental condition (example would be when a person is under anesthesia). -May be permanent in situation such as disability (example would be Alzheimer’s disease) |
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Legal Guardian
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-If person is unable to make own decisions, a legal guardian can be appointed to handle person’s affairs, including medical decisions.
-This is usually a family member. -The legal guardian must take into consideration patient’s wishes that were expressed while competent -A decision made while person is competent remains if declared later to be incompetent (i.e. medical decisions, will) |
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Legal Competency
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-Whether person is legally competent to stand trial is determined by whether they are able to participate in the legal process or whether the person’s illness might affect ability to participate.
-Person must be alert, oriented & able to understand complexity of situation |
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Criminal Responsibility
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Premise is that person should not be blamed for crimes they did not know they were doing or when they could not stop self (psychotic, retarded etc.)
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Determination of Condition When Crime Was Committed
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1. Know nature & quality of act (unable to understands right or wrong or consequence)
2. Impulsively driven to commit criminal act with a lack of premeditation & strong urge to do it (was there intent?) 3. Lacks capacity to grasp wrongfulness of act or conform conduct to requirements of law (most common criteria) this excludes sociopath personality. |
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ETHICAL ASPECTS OF MENTAL HEALTH CARE, STANDARDS OF CARE
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-Ethics is standard of behavior or belief valued by individual or group.
-Describes what should be- goal to aspire to achieve. -This evolves as society changes views, but does not mean all agree. -Professional code of ethics provides a framework for decision making by members Nurses’ code of ethics emphasizes accountability of profession. |
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ANA Code of Ethics
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-Revised in 2001 for 1st time in 25 years to meet challenges of 21st century in partnership with patients, family & community.
-Explains mission of nursing & how nurses work with public to promote health, prevent illness & promote recovery |
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Standards of Practice for Mental Health Nurses
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This differs from minimal qualifications for licensure.
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Focus of Standards of Practice for Mental Health Nurses
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-is to elevate practice of members by setting standards of excellence.
-It is important to provide patients with a high level of competency by all nurses regardless of place care taking place. -Nurses are responsible for staying current with existing standards. -Nurses are held legally responsible for knowing & adhering to standards. -Nurses are held to standard of care exercised by other nurses possessing same degree of skill or knowledge in same or similar circumstances ~This is determination of whether negligence or malpractice has occurred~ |
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MH Standards
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See front of book for specifics
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ANA Nurses Bill of Rights
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Developed 2001 to advocate on behalf of nurses & the profession by establishing what nurses can expect from society to improve workplace & ensure ability to provide safe, quality patient care & provide guidance on nursing profession’s position
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Nurses have right to:
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-safe work environment,
-adhere to professional standards in providing patient care -provide ethical practice to ensure safe care -advocate freely for self & patients |
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Nurses have the right to (con't):
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-practice in manner to fulfill obligation to society & patients.
-practice in environment allowing them to act in accordance with professional standards & legal scope of practice -work in an environment that supports & facilitates ethical practice -freely & openly advocate for self & patients without fear of retribution -receive fair compensation for work consistent with knowledge, experience & professional responsibilities -negotiate conditions of employment either individually or collectively in all practice settings |
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Therapeutic Milieu
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-Environment of treatment facility is structured to provide a stable setting that facilitates development & implementation of treatment.
-Inpatient unit provides a safe setting for control of disturbing maladaptive responses to stabilize behaviors. -Outpatient facility is structured to assist individual in achieving goals to maintain or improve functioning. |
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Aspects of Milieu Therapy
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-Containment
-Support -Structure -Involvement |
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Containment
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is used to meet physical needs & provide safety by setting limits & control on behavior when person does not have self-control.
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Support
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is provided with acceptance of person & encouragement to improve self-confidence.
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Structure
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is provided through an organized & predictable schedule, which will decrease the person’s anxiety.
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Involvement
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Involvement of patient is encouraged throughout interactions in the social environment of activities. Providing validation affirms the individual’s worth.
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Nurse Patient Relationship
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-The short time of treatment & role within any clinical setting impacts the relationship that a nurse establishes with patients.
-The interpersonal relationship involves sharing of thoughts feelings & emotions in an empathetic manner while remaining objective to provide a corrective emotional experience for the patient. |
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Therapeutic Relationship
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-Differs from social relationship as focus is on significant personal issues of other person to solve problems.
-Nurse self-discloses only to meet treatment goals. -Generally, time limited, terminating when goals are met or when nurse or patient leaves treatment setting. |
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Boundaries in Therapeutic Relationship
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-Difficult to maintain at times, may become blurred if relationship moves outside limits of relationship, & becomes social or personal, or nurse’s needs take precedence over patient.
-Nurse must constantly be aware of & maintain own role. -When nurse does something special, different or unusual for a patient this is a RED FLAG! |
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Boundary Issues
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-Nurse must define the roles & set limits.
-Time of interactions is used as means of setting limits Place/physical space of interactions-use good judgment. -Must be private enough for confidentiality, but not in area where patient or nurse feels unsafe or uncomfortable. -Money/gifts are generally not appropriate. -Must evaluate intention of gift in context of the patient. -Clothing can impact relationship if either wears inappropriate dress (too tight, short, revealing etc.) |
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Phases of Relationship
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-This process evolves through interlocking, overlapping phases
-Not every nurse patient relationship will go through all of the phases. -Patient may be too ill or unwilling to participate, patient may be discharged, nurse may not be working etc. |
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Phases of Relationship
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-Pre-interaction Phase
-Introductory or Orientation Phase -Working Phase -Termination Phase |
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Pre-interaction Phase
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-Typical concerns by students involve safety, what to say, how to approach patient etc.
-Planning for interactions is important so that relationship can be established -Concern, respect & interest conveys a caring attitude -Remember that any anxiety you feel is much more intense for patient |
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Introductory or Orientation Phase
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-Tasks include establishing trust, understanding, acceptance & open communication.
-Introduction of each person & purpose of interactions is established. -The length of time of interaction varies |
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Issues during Orientation
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Parameters of relationship:
-who nurse is & role in the relationship, purpose of the relationship. -Formal or informal contract can be planned. -This includes place, time, date, duration of meetings & goals. -Termination begins during this phase. -This can occur when student rotation ends, patient is discharged, goals met etc. |
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Working Phase
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-Nurse & patient identify & explore areas that are causing problems for patient.
-Previous problem solving techniques, communication style, & coping skills are discussed. -Behaviors that are more effective are identified & may be tried through role-playing etc. -Evaluate problems & goals & redefine them as needed |
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Issues That May Interfere During Working Phase:
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-Testing/manipulation may occur as the patient struggles with issues.
-Transference may take place if patient has thoughts or feelings for nurse that are associated with significant person from past (anger, jealousy, etc.). -Counter transference occurs if nurse has thoughts or feelings for patient related to a person from past. |
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Termination Phase
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-Progress is reviewed to determine if goals have been met & what remaining goals need to be addressed.
-Both patient & nurse may have strong feelings (abandonment, loss etc). -When these feelings are expressed, both can learn from experience. -Defenses may arise during this phase including avoidance or hostility by patient if not able to deal with feelings directly. -Nurse may feel guilt or responsibility toward patient. |
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Communicating Feelings Effectively
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Occurs on a continuum from passive to aggressive.
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Assertiveness
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-Asking for what one wants or acting in ways to get what one wants in manner that respects rights & feelings of other people.
-This type of communication conveys a sense of self-assurance -Asking for what one wants or acting in ways to get what one wants in manner that respects rights & feelings of other people. -This type of communication conveys a sense of self-assurance |
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Assertive Behaviors
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-Speak clearly & distinctly
-Observe personal space -Make appropriate eye contact that is direct but not intrusive -Gestures should emphasize speech but doesn’t distract or appear threatening |
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Aggressiveness
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-Aggressive person ignores the rights of others.
-Acts as if must fight for own interests & expects same from others. -May be physically or verbally violent. -Often lacks self-confidence by acting in ways that drives others away this reinforces poor self-worth. -Aggressiveness occurs as a response to threat that is either real or imagined. -This threat may be internal or external. |
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Aggressive Behaviors
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-Verbal responses are loud
-Person’s use of body invades personal space of others. -When speaking loudly they use language with lots of emphasis. -Eye contact is intrusive & may include stares or glares. |
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Passiveness
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-Passive person is unable to recognize or communicate feelings directly.
-Passive person subordinates own rights to meet perception of others needs. -This negates their feelings & needs leading to further decreased self-respect. -By trying to hide anger or other feelings, this increases person’s own anxiety |
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Passive Behaviors
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-Speech is soft with weak responses. They may act in a childlike manner.
-There is little eye contact. -Body language communicates shyness & self-doubt (slouches, head down, arms folded, etc.) |
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Major Theories
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-Medical/psychobiological: medication
-Psychoanalytical: psychoanalysis -Behaviorists: behavior modification -Social-Interpersonal: group,family,individual therapy |
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1963 Community Mental Health Center Act
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-Law passed regarding moving treatment from hospitals into outpatient care.
-Focus shifted to preventive care = Least restrictive care. |
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Minimum requirement for Legal Competency
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Person must be alert, oriented, and able to understand complexity of situation
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Qualities of Effective Mental Health Nursing
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-Respect for the client
-Availability -Spontaneity -Hope -Acceptance -Sensitivity -Vision -Accountability -Advocacy -Spirituality -Empathy |
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Personal Integrity of Mental Health Nursing
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-solitude
-personal physical health -internal stress signals -burnout |
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In Defusing Anger, Frustration, and Conflict, PARENTS:
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-lose rational perspective when it comes to issues involving their own child
-want to protect child from pain -feel vulnerable -have fear of the unknown -Parents in hospital situation may feel judged as parents by staff |
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In determining the Etiology of Hostility or Anger
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Which is present?
Pain, Stress, or Fear |
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Grief/Depression
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Suggested Response:
-Listen, reframe, empathize. -Consider social worker or psychiatric consult |
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Personality problems/Behavioral problems
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Confront with manager or physician (person in position of perceived power) in order to define acceptable behavior
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Responses to Medications
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1. Different cultures respond differently to medications (i.e., African and Asian-Americans are slow metabolizers of antipsychotic and antidepressants and have more side effects)
2. Most clinical trials have been done on white men with results generalized to other patients |
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