Unit 1 Course Introduction Mental Health and Illness Legal/Ethical Professional Standards

Qualities of Mentally Healthy Person Relative happiness Self control Reality orientation Effective at work and social roles Accurate self concept (locus of control, self esteem)

Relative happiness

Self control

Reality orientation

Effective at work and social roles

Accurate self concept (locus of control, self esteem)

DSM IV Diagnostic and Statistical Manual Axis I: Major mental disorder Axis II: Personality disorder/mental retardation Axis III: General Medical Conditions Axis IV: Psychosocial/Environmental factors affecting the situation Axis V: Global Assessment of Functioning Scale (GAF)

Axis I: Major mental disorder

Axis II: Personality disorder/mental retardation

Axis III: General Medical Conditions

Axis IV: Psychosocial/Environmental factors affecting the situation

Axis V: Global Assessment of Functioning Scale (GAF)

Professional Standards ANA Standards from Cover of Text Patient Care Standards Rationale for Standards RN responsibility-how it fits with legal and ethical aspects of the profession

ANA Standards from Cover of Text

Patient Care Standards

Rationale for Standards

RN responsibility-how it fits with legal and ethical aspects of the profession

Ethical Positions Beneficence: duty to do what is of benefit to others Autonomy: Right to self determine choices affecting oneself Justice: right to fair treatment Fidelity (non maleficence):doing no wrong to client, acting with loyalty

Beneficence: duty to do what is of benefit to others

Autonomy: Right to self determine choices affecting oneself

Justice: right to fair treatment

Fidelity (non maleficence):doing no wrong to client, acting with loyalty

Patient’s Bill of Rights Maintain civil rights: vote, contracts, religious Client consent: refuse treatment, grievance Communication: mail and phone/full and private Freedom from harm: unnecessary restraint, isolation, medication Dignity/respect Confidentiality: both written (libel) and oral (slander) Participation in care plan

Maintain civil rights: vote, contracts, religious

Client consent: refuse treatment, grievance

Communication: mail and phone/full and private

Freedom from harm: unnecessary restraint, isolation, medication

Dignity/respect

Confidentiality: both written (libel) and oral (slander)

Participation in care plan

Other legal points of interest Parens patriae: state as “parent” Police power:right of state to protect society Least restrictive alternative—guiding principle in mental health Tarasoff decision—duty to warn

Parens patriae: state as “parent”

Police power:right of state to protect society

Least restrictive alternative—guiding principle in mental health

Tarasoff decision—duty to warn

Voluntary Admission Signs self in, needs order, may be instead of involuntary admit. For insurance to pay, often must show major mental illness, dangerousness, inability to manage as outpatient, start of Rx requiring close supervision If requests d/c prematurely may get: regular d/c, AMA, or commitment petition filed.

Signs self in, needs order, may be instead of involuntary admit.

For insurance to pay, often must show major mental illness, dangerousness, inability to manage as outpatient, start of Rx requiring close supervision

If requests d/c prematurely may get: regular d/c, AMA, or commitment petition filed.

Involuntary Admission If police bring in—called IDO immediate detention order, requires exam then decision re status EDO—emergency detention order, signed by qualified medical personnel (ie MD). To court in 72 hours for decision. If the decision is to commit at this time, it is called a temporary commitment (90 + 90). This decision is based on four criteria. After 90 + 90 can be placed on indefinite commitment with a yearly review.

If police bring in—called IDO immediate detention order, requires exam then decision re status

EDO—emergency detention order, signed by qualified medical personnel (ie MD). To court in 72 hours for decision.

If the decision is to commit at this time, it is called a temporary commitment (90 + 90). This decision is based on four criteria.

After 90 + 90 can be placed on indefinite commitment with a yearly review.

Types of Therapeutic Approaches (review!) Psychoanalytic Rational Emotive Therapy Cognitive Therapy Behavioral Therapy Milieu Therapy Group Therapy Medical/biologic therapy

Psychoanalytic

Rational Emotive Therapy

Cognitive Therapy

Behavioral Therapy

Milieu Therapy

Group Therapy

Medical/biologic therapy

Stages of Therapeutic Relationship 1. Preorientation; prep, values clarification, history 2. Orientation: establish trust, boundaries, and client contract 3. Working: deal with problems and changing behavior 4. Termination: discuss progress, referral, say good bye

1. Preorientation; prep, values clarification, history

2. Orientation: establish trust, boundaries, and client contract

3. Working: deal with problems and changing behavior

4. Termination: discuss progress, referral, say good bye

Refresh yourself regarding: HIPAA Professional Dress Know where to go for your clinical

HIPAA

Professional Dress

Know where to go for your clinical

Unit 2 Communication and Assessment Therapeutic communication Dealing with Upset people Anxiety levels, Mental Mechanisms Intro to assessment

Review of Communication Issues Content and Process in a verbal message Congruent and Incongruent communication Therapeutic use of self Differentiate transference and counter-transference Positive regard Empathy versus sympathy

Content and Process in a verbal message

Congruent and Incongruent communication

Therapeutic use of self

Differentiate transference and counter-transference

Positive regard

Empathy versus sympathy

Therapeutic approaches Accepting, recognizing Offering self Broad openings and general leads Restating and reflecting Encouraging comparison and description of perception Making observations Focusing Exploring Seeking clarification Presenting reality Voicing doubt Verbalizing the implied Encouraging formulation of a plan of action

Accepting, recognizing

Offering self

Broad openings and general leads

Restating and reflecting

Encouraging comparison and description of perception

Making observations

Focusing

Exploring

Seeking clarification

Presenting reality

Voicing doubt

Verbalizing the implied

Encouraging formulation of a plan of action

Non therapeutic approaches and common errors False reassurance Agreeing/disagreeing Giving advice Probing Defending Asking why Belitting feelings Using denial Interpreting Changing the subject Rejecting Repetitive closed questions Body language indicates hurry or frustration “ Is there anything you want to talk about?”

False reassurance

Agreeing/disagreeing

Giving advice

Probing

Defending

Asking why

Belitting feelings

Using denial

Interpreting

Changing the subject

Rejecting

Repetitive closed questions

Body language indicates hurry or frustration

“ Is there anything you want to talk about?”

Fight or Flight Fight Responds to stress, threat and uncertainty with conflict, anger, violence Review Symptoms of Fight or Flight Response! Flight Responds to stress, threat, and uncertainty with anxiety, fear, etc

Fight

Responds to stress, threat and uncertainty with conflict, anger, violence

Review Symptoms of Fight or Flight Response!

Flight

Responds to stress, threat, and uncertainty with anxiety, fear, etc

Dealing with an Upset Person Body language: Calm, warm, open posture at a side angle. Good eye contact, no staring. Voice tone: Assertive, audible, calm, low, slow. Keep verbal responses short and simple. Your response should match their behavior—they talk, you talk; they act; you act. Give choice between 2 acceptable options

Body language: Calm, warm, open posture at a side angle. Good eye contact, no staring.

Voice tone: Assertive, audible, calm, low, slow.

Keep verbal responses short and simple.

Your response should match their behavior—they talk, you talk; they act; you act.

Give choice between 2 acceptable options

Conflict Management and Anger Anger is a problem if it explodes out uncontrollably or if it is held in excessively Staff and clients both have anger issues Often anger leaks out in subtle ways: sarcasm, excessive humor, making people wait, silent treatment, physical ailments, overly polite behavior, crying, acting superior

Anger is a problem if it explodes out uncontrollably or if it is held in excessively

Staff and clients both have anger issues

Often anger leaks out in subtle ways: sarcasm, excessive humor, making people wait, silent treatment, physical ailments, overly polite behavior, crying, acting superior

Styles of Conflict Management—Which fit you the best? Forcing—I win, you lose Confronting—Care enough to be honest Compromising—Both partly win Smoothing—I give in to make you feel better Withdrawing—Anger is too scary to face, I withdraw

Forcing—I win, you lose

Confronting—Care enough to be honest

Compromising—Both partly win

Smoothing—I give in to make you feel better

Withdrawing—Anger is too scary to face, I withdraw

General Tips for Conflict Management Realize that anger is a normal emotion, discover what the anger is about! Find out/ask for what you need Deal with the person you are angry with Each person is responsible for his/her own behavior Think before you speak

Realize that anger is a normal emotion, discover what the anger is about!

Find out/ask for what you need

Deal with the person you are angry with

Each person is responsible for his/her own behavior

Think before you speak

More General Tips… What are the implications of fighting this battle? Worth it? Respect for the person is vital If you have a complaint, bring a solution to the table. Don’t just bring problems… Bring everyone who has a real stake in the issue together to deal with it.

What are the implications of fighting this battle? Worth it?

Respect for the person is vital

If you have a complaint, bring a solution to the table. Don’t just bring problems…

Bring everyone who has a real stake in the issue together to deal with it.

Peplau’s Mild Anxiety Increased ability to perceive, heightened senses Effectively learn, work toward goal, good awareness Slight restlessness, mild tension No intervention needed

Increased ability to perceive, heightened senses

Effectively learn, work toward goal, good awareness

Slight restlessness, mild tension

No intervention needed

Peplau’s Moderate Anxiety Narrowed perceptual field, sees less of what is going on—selective inattention Able to do some problem solving with help Shaky voice, less concentration, headache, insomnia, pacing, some minor fight or flight symptoms

Narrowed perceptual field, sees less of what is going on—selective inattention

Able to do some problem solving with help

Shaky voice, less concentration, headache, insomnia, pacing, some minor fight or flight symptoms

Interventions for Moderate Anxiety Problem solving/talk therapy. “Sit down with client individually BID for ___min. allow client to vent concerns and assist client to identify positive problem solving strategies.” Cognitive reframing Teaching Anxiety reduction techniques – relaxation training, meditation, counting, deep breathing

Problem solving/talk therapy. “Sit down with client individually BID for ___min. allow client to vent concerns and assist client to identify positive problem solving strategies.”

Cognitive reframing

Teaching

Anxiety reduction techniques – relaxation training, meditation, counting, deep breathing

Peplau’s Severe Anxiety Small perceptual field, attend to irrelevant detail or scattered thoughts Self absorbed, feedback doesn’t help much Impending dread/doom, purposeless activity, hypervent, tachy, loud rapid speech Can’t effectively problem solve or see connections

Small perceptual field, attend to irrelevant detail or scattered thoughts

Self absorbed, feedback doesn’t help much

Impending dread/doom, purposeless activity, hypervent, tachy, loud rapid speech

Can’t effectively problem solve or see connections

Peplau’s Panic level of Anxiety Terror and emotional paralysis, hallucinations or delusions take place of reality Mute or extreme agitation, irrational, hypervigilant, hyperactive Sleepless, not eating, all fight or flight in place

Terror and emotional paralysis, hallucinations or delusions take place of reality

Mute or extreme agitation, irrational, hypervigilant, hyperactive

Sleepless, not eating, all fight or flight in place

Interventions for all levels of Anxiety Maintain your presence Decrease environmental stimuli Remain calm Speak slowly, clearly, simply Base further intervention on level of anxiety and situation

Maintain your presence

Decrease environmental stimuli

Remain calm

Speak slowly, clearly, simply

Base further intervention on level of anxiety and situation

Interventions for Severe or Panic Anxiety Medication—anti-anxiety or anti-psychotic Provide short, firm concrete directions to assist the client to calm Protect the client from self injury, either intentional or related to inattention or poor reality testing Protect the milieu from disruption and injury—discuss

Medication—anti-anxiety or anti-psychotic

Provide short, firm concrete directions to assist the client to calm

Protect the client from self injury, either intentional or related to inattention or poor reality testing

Protect the milieu from disruption and injury—discuss

Criteria for Restraint and Seclusion Client imminently harmful to self or others Client endangering facility Less restrictive measures are not satisfactory Client request (rare) Must show that criteria were met in your documentation or be at risk for false imprisonment

Client imminently harmful to self or others

Client endangering facility

Less restrictive measures are not satisfactory

Client request (rare)

Must show that criteria were met in your documentation or be at risk for false imprisonment

Proper Restraint/Seclusion order includes: Type of restraint or seclusion (discuss) Reason (from frame earlier) Specific time limits (agency and state boundaries apply). NO PRN order. MD signature. Agency may specify that MD see the client within a certain time frame.

Type of restraint or seclusion (discuss)

Reason (from frame earlier)

Specific time limits (agency and state boundaries apply). NO PRN order.

MD signature. Agency may specify that MD see the client within a certain time frame.

RN Care Issues in R/S: Frequent checks or constant observation, documented (aid can do). Protect client privacy; hygiene, ROM, body alignment (discuss frequency). Safe/secure application of restraints (will hold ct, applied correctly). Assess circulation, abrasion, alignment, warmth, no harmful objects in area. Nutrition, fluid, elimination needs Q2hr Reasonable release criteria set, moniter progress towards release at least Q2hr

Frequent checks or constant observation, documented (aid can do).

Protect client privacy; hygiene, ROM, body alignment (discuss frequency).

Safe/secure application of restraints (will hold ct, applied correctly). Assess circulation, abrasion, alignment, warmth, no harmful objects in area.

Nutrition, fluid, elimination needs Q2hr

Reasonable release criteria set, moniter progress towards release at least Q2hr

Issues with R/S Assault: verbal threat, namecalling Battery: physical abuse, harm, unwelcome contact False imprisonment: habeas corpus Can medicate against will only in case of imminent risk of violence to self or others, otherwise not (discuss court order exception)

Assault: verbal threat, namecalling

Battery: physical abuse, harm, unwelcome contact

False imprisonment: habeas corpus

Can medicate against will only in case of imminent risk of violence to self or others, otherwise not (discuss court order exception)

Other considerations… Get uninvolved clients out of the way One person does the talking with client Do not attempt to be a hero, always have adequate help before intervening Once a limit has been set, it should not be negotiated, sends message that fosters acting out. Least restrictive alternative

Get uninvolved clients out of the way

One person does the talking with client

Do not attempt to be a hero, always have adequate help before intervening

Once a limit has been set, it should not be negotiated, sends message that fosters acting out.

Least restrictive alternative

Defense Mechanisms (ch 13) On a continuum of relative maturity: mature-neurotic-immature-psychotic All serve to protect the human from perceived threats (conflict, shame, fear, anger) Relatively unconscious, though we can become aware of them

On a continuum of relative maturity: mature-neurotic-immature-psychotic

All serve to protect the human from perceived threats (conflict, shame, fear, anger)

Relatively unconscious, though we can become aware of them