Introduction to Psychiatric Nursing Module 2: Concepts

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Introduction to Psychiatric NursingModule 2
Concepts

• RNSG 2213

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History Concepts

• How were mentally ill treated prior to1790s?
• Banishment
• Confinement
• What were attitudes toward them?
• Possessed by the devil
• Lacked basic human qualities

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St. Mary of Bethlehem Hospital, London
(Bedlam) Opened to lunatics 1403
Visitors pay for entertainment
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History Concepts

• Period of Enlightenment begins in 1790s
• 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
  1820s

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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

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Dorthea Dix Asylum in North Carolina
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Austin, Texas State Insane Asylum 1851
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Era of Psychotropic Drugs

• 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.

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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

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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

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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
  clients threat of suicide or of harm to self or
  others

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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

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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

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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?)

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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 persons thought,
  perception of reality, emotional process
• and/or
• Grossly impairs behavior as manifested by a
  recent event of disturbed behavior (Gravely
  disabled)

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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.

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Commitments, contd

• 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

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Involuntary Commitments

• Emergency Mental Illness Commitment Allows Mental
  Health Deputies (Crisis Intervention 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.

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Involuntary Commitments, contd

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

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Involuntary Commitments, contd

• 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

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Involuntary Commitments, contd

• Extended Mental Health Commitment
• Very strong evidence needed
• Commitment is up to 1 year.

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Last but not least . . . .

• All involuntary commitments can include
  court-ordered medications
• All commitments discussed previously can apply to
  Chemical Dependency

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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?

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PSYCHOTHERAPEUTIC MANAGEMENT

• TOOLS ARE
• SELF ? DRUGS ? ENVIRONMENT
• ? Therapeutic Use of SELF (Nurse-Client
  Relationship)
• ? DRUGS Psychopharmacology
• ? ENVIRONMENT Therapeutic Milieu

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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.