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Orientation and Foundations of Psychiatric Mental Health Nursing

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Title: Orientation and Foundations of Psychiatric Mental Health Nursing


1
Orientation and Foundations of Psychiatric
Mental Health Nursing
2
Definition of Psychiatric Mental Health Nursing
  • A specialty within the nursing profession that
    focuses primarily on the use of therapeutic
    interpersonal interactions and biologic and
    interpersonal interventions with clients.
  • PMHN focuses on human aspects and responses to
    illness and is therefore part of all areas of
    nursing.

3
Four Core Mental Health Practice Areas
  • Psychiatric nursing
  • Psychiatry
  • Psychology
  • Social work

4
Professional attributes of psychiatric nurses
include
  • Promotion of mental health
  • Prevention and treatment of mental disorders
  • Rehabilitation after the disorder

5
Historical Overview of Psychiatry
6
  • Prior to the 19th century, practitioners would
    say that mentally ill patients had idiocy most
    treatments were cruel and inhumane
  • Police took people to madhousesa private
    boarding home without legal or therapeutic
    guidelines to govern care
  • At the end of the 19th century, private and
    public psychiatric hospitalizations began
    providing mostly custodial care
  • The 1950s saw the advent of new meds that
    revolutionalized the treatment and decreased the
    number of hospitalized patients

7
1960s- Deinstitutionalization
  • In 1963, President Kennedy decided that you
    couldnt institutionalize.
  • The goal of deinstitutionalization was to
    replace the cold mercy of custodial isolation
    with the open warmth of community concern and
    capability.
  • This shifted the emphasis of mental health care
    from hospitals to community mental health centers.

8
1970s-1990s
  • Discovery of neurobiological factors influencing
    mental disease
  • The decade of the 1990s was named by Congress as
    the Decade of the Brain
  • Proliferation of newer biochemical therapies
    effective in treating mental disorders
  • Expanding scientific technology-MRI, CT, and PET
    scans

9
The Millennium and Beyond
  • Shorter hospital stays secondary to economic
    pressures from managed care
  • Care today emphasizes community-linked care
  • Development of new indications for the
    antidepressant medications
  • Continued investigation of the brain and
    neurotransmitters

10
Concept of Nature vs Nurture
  • Psych d/os formerly were thought to rise from
    some disruption in early life experiences
  • Rigid toilet training led to unrelenting thoughts
    and behaviors like repeated hand washing (OCD)
  • Later a new wave of theories of causation then
    emerged
  • Biologic and genetic factors accounted for the sx
    of psychiatric illness, i.e., people were manic
    depressive not because of poor parenting or
    difficulty in childhood but because of their
    genetic makeup

11
Concept of Nature vs Nurture
  • We now know that neither of these extreme
    positions fully explain the complexity of the
    brain
  • It is much more probable that psychiatric
    disorders result from some combination of the 2
    theories

12
The Nurse-Client Relationship An Art and a
Science
  • First described by Hildegard Peplau in her text
    Interpersonal Relations in Nursing (1952)

13
The Art
  • The art of caring is the basis for PMHN and is
    embodied in the nurse-client relationship.
  • The nurse-client relationship is often referred
    to as a therapeutic alliance which is used to
    effect change, promote growth, and heal mental
    and emotional wounds.

14
Core Characteristics of a Successful Therapist
  • Empathy
  • Warmth
  • Genuineness
  • Respect
  • Concreteness
  • Immediacy
  • Confrontation
  • Self-Disclosure

15
The Science
16
I. Principles of the Nurse-Client
Relationship
17
Principles of the Nurse-Client
Relationship
  • The relationship is therapeutic rather than
    social
  • The focus remains on the clients issues rather
    than on the nurses or other issues
  • The relationship is purposeful and goal directed
  • It is objective versus subjective in quality
  • It is time limited versus open ended

18
Therapeutic vs Social
  • A therapeutic relationship is formed to
  • help clients solve problems
  • make decisions
  • achieve growth
  • learn coping strategies
  • let go of unwanted behaviors
  • reinforce self-worth
  • examine relationships

19
Therapeutic vs Social
  • The meetings between nurse and client are not for
    mutual satisfaction.
  • The nurse can be friendly with the client, but is
    not there to be the clients friend.
  • The majority of the interaction is focused and
    therapeutic.

20
Client Focus
  • During an interaction, a client may redirect the
    focus away from self by changing the subject,
    talking about the weather, etc.
  • The nurse needs to recognize this as a divergent
    tactic, confront this behavior, and refocus the
    client.

21
Goal Direction
  • The primary purpose of a therapeutic relationship
    is helping clients to meet adaptive goals.
  • Nurse and client work together to identify
    problematic areas in clients life
  • Once goals are established, the nurse and client
    agree to work toward those goals.

22
Objective vs Subjective
  • Nurses can be therapeutic only if they remain
    objective.
  • Objectivity refers to remaining free from bias,
    prejudice, and personal identification in
    interaction with the client and being able to
    process information based on facts.
  • Subjectivity refers to emphasis on ones own
    feelings, attitudes, and opinions when
    interacting with the client.

23
Time-Limited Interactions
  • Time of meetings
  • Number of meetings that will take place
  • Provides structure
  • Lets client know that relationship will end

24
Stages of the Nurse-Client Relationship
  • Preorientation phase
  • Orientation phase
  • Working phase
  • Termination phase

25
Preorientation Phase
  • Takes place prior to meeting with the client
  • 1st gather data about the client, his or her
    condition, and the present situation
  • Nurse then examines his or her thoughts,
    feelings, perceptions, and attitudes about this
    particular client

26
Orientation Phase
  • The nurse-client become acquainted build trust
    and rapport
  • A contract is established
  • Includes time and place for the meeting, as well
    as the purpose of the meetings
  • Dependability is imperative for both the nurse
    and the client
  • Client strengths, limitations, and problem areas
    are identified
  • Outcome criteria and a plan of care are
    established

27
Working Phase
  • Orientation phase ends and working phase begins
    when the client takes responsibility for his or
    her own behavior change
  • Client shows commitment to working on issues that
    have caused a life disruption
  • Clients needs are prioritized- safety and health
    come first
  • RN assists the client to change problematic
    behaviors in a safe environment

28
Termination Phase
  • Relationship comes to a close
  • This phase begins in the orientation phase when
    meeting times are established- lets the client
    know that the relationship will come to an end
  • Avoids confusing the client who may be unable to
    recognized boundaries in a relationship
  • Termination occurs when the client has improved
    or has been discharged

29
II. Nursing Scope of Practice
30
Nursing Scope of Practice
  • Standards of care and practice for psychiatric
    mental health nurses were developed by the
    American Nurses Association and continue to
    describe functions.

31
Basic Practice Level
  • At the basic practice level, nurses can intervene
    in the following ways
  • Counseling
  • described by the ANA as including interviewing
    and communication techniques, problem solving,
    crisis intervention, stress management, and
    behavior modifications

32
Basic Practice Level (cont.)
  • Milieu Therapy
  • The environment is used as a therapeutic tool
    to modify behaviors, teach skills, and encourage
    communication between the client and others.
  • Self-Care Activities
  • Encouraging independence within a clients
    ability and capacity urges clients to take
    responsibility for their care thus improving
    their self esteem.

33
Basic Practice Level (cont.)
  • Psychobiologic Interventions
  • Knowledge of medications used in the
    psychiatric setting
  • Health Teaching
  • Health Promotion and Health Maintenance
  • Case Management
  • Coordinates comprehensive health
    services and ensures continuity of care

34
Advanced Practice Level
  • The following interventions may be employed by
    clinical specialists and nurse practitioners who
    are certified in advanced psychiatric mental
    health nursing
  • Psychotherapy
  • Prescription of Pharmacologic Agents
  • Consultation
  • Education

35
III. Mental Health and Mental
Disorder
36
Defining and Classifying Mental Health and Mental
Disorder
  • The ANA defines mental health as a state of
    well-being in which individuals function well in
    society and are generally satisfied with their
    lives.
  • Results in socially acceptable behavior and the
    ability to respond productively and appropriately
    in the environment

37
Defining and Classifying Mental Health and Mental
Disorder
  • Mental disorder is a disturbance in an
    individuals thinking, emotions, behaviors, and
    physiology.
  • Leads to problems with behavior, relationships,
    and functioning.

38
Mental Illness and Mental Health Continuum
  • Mild?joys, sorrows, and anxiety levels that aid
    in the work of living
  • Mild-Moderate?psychophysiologic factors affecting
    medical conditions
  • Moderate-Severe?anxiety d/os, dissociative d/os,
    somatoform d/os, personality d/os, and eating
    d/os
  • Severe-Psychosis?depressive d/os, bipolar d/os,
    schizophrenic d/os, and cognitive d/os

39
IV. Psychiatric Diagnoses
40
Psychiatric Diagnoses
  • Precise descriptions and classifications of
    mental disorders
  • Represents a specific set of sx or syndrome
  • Allows for easier communication among mental
    health care providers
  • Permits Rx based on pts dx
  • Prognosis

41
Diagnostic Nomenclatures
  • A nomenclature of psychiatric diagnoses developed
    by the APA is widely accepted in the US as the
    official diagnostic criteria in clinical,
    research, and educational settings.
  • The diagnoses are published in the Diagnostic and
    Statistical Manual of Mental Disorders, 4th
    edition. (DSM IV-TR)

42
DSM IV-TR
  • A multiaxial classification scheme that allows
    for the interrelation of biological,
    psychological, and social aspects of an
    individuals condition.
  • Axis I the psychiatric diagnosis
  • Axis II personality disorders and mental
    retardation
  • Axis III general medical conditions
  • Axis IV psychosocial and environmental problems
  • Axis V GAF- rates the overall psychological
    functioning of the client on a scale of 0-100.

43
NANDA
  • Nomenclature of nursing diagnoses
  • Many applicable in the psychiatric setting

44
V. The Nursing Process
45
The Nursing Process
  • A scientific, problem-solving method that assists
    nurses in total client care.
  • Consists of 6 steps
  • Assessment
  • Diagnosis
  • Outcome Identification
  • Planning
  • Implementation
  • Evaluation

46
VI. Therapeutic Treatment Modalities
47
Therapeutic Rx Modalities
  • Traditional inpatient hospitalization has been
    replaced with an entire range of care options
  • Rx options include
  • Inpatient hospitals
  • Outpatient day treatment programs
  • Clinics
  • Home care
  • Community centers
  • Crisis centers
  • Place of employment/school

48
Therapeutic Rx Modalities (cont.)
  • Types of Therapies
  • Interactive therapies- includes all of those in
    which the client has interpersonal contact with 1
    or more therapists and includes interaction with
    other clients
  • Biologic therapies- includes the use of
    medications and ECT

49
VII. Current Epidemiology and Research
50
Current Epidemiology and Research
  • Approx 28 of Americans over the age of 18 suffer
    from a mental or addictive disorder in a 1 year
    period
  • See page 11 in the text for prevalence of psych
    d/os in the US

51
VIII. Prevention of Disorders
52
Prevention of Disorders
  • Gerald Caplan (1964) proposed a model for
    preventive care of persons with mental disorders.
  • Model proposes 3 levels of preventions
  • Primary
  • Secondary
  • Tertiary

53
Primary Prevention
  • Focuses on reduction of the incidence of mental
    disorders within the community
  • Emphasizes health promotion and prevention
  • Example Teaching stress reduction techniques to
    any population

54
Secondary Prevention
  • Directed toward reducing the prevalence of mental
    disorders through early identification and early
    Rx of those problems
  • Example assessing sx of depression such as sleep
    disturbances, appetite changes, diminished
    interest during routine interview with client if
    problem identified- treat

55
Tertiary Prevention
  • Has the dual focus of reducing residual effects
    of the disorder and rehabilitating the individual
    who experienced the mental disorder
  • Example Social skills training to a schizophrenic

56
IX. Roles of the Mental Health Team
57
Roles of the Mental Health Team
  • Psychiatric Nurse
  • Has the most widely focused position description
    of any of the member roles
  • Interacts with clients in individual and group
    settings
  • Manages client care
  • Administers and monitors meds
  • Teaches both clients and families
  • Acts as a client advocate

58
Roles of the Mental Health Team
  • Psychiatric Social Worker
  • Graduate level position
  • Work with clients on an individual basis
  • Conduct group therapy sessions
  • Act as liaisons with the community to place
    clients after discharge

59
Roles of the Mental Health Team
  • Psychiatrist
  • Licensed medical physician who specializes in
    psychiatry
  • Prescribe and monitor meds
  • Admit clients into acute care settings
  • Administer ECT
  • Conduct individual and family therapy

60
Roles of the Mental Health Team
  • Psychologist
  • Licensed individual with a doctoral degree in
    psychology
  • Assess and treat psychologic and psychosocial
    problems of individuals, families, or groups
  • Do not prescribe or administer medications
  • Administer psychometric tests that aid in the
    diagnosis of disorders

61
Roles of the Mental Health Team
  • Marriage, Family, Child Counselor
  • Licensed individuals who frequently work in
    private practice
  • Prepared to work with individuals, couples,
    families, and groups
  • Emphasize the interpersonal aspects of achieving
    and maintaining relationships

62
Roles of the Mental Health Team
  • Case managers
  • Facilitate the delivery individualized,
    coordinated care in cost-effective ways
  • Need to know the various types of hospitalization
    and outpatient care settings, the coverage
    offered by different payers, and the impact of
    state and federal legislation

63
X. Trends and Issues of the Future
64
Trends and Issues of the Future
  • Dominant issue in mental health is managed care
  • The outcome of managed care for clients and
    families with mental disorders are reported to be
    ineffective
  • Because of managed care and lack of funding,
    clients are often discharged before they are
    ready to leave the hospital
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