Ramapo work shop_sept_2015

+
Maryann Ryan, MSN, APN, NP-C, PMHNP-BC
Ramapo 2015
PSYCHIATRIC
NURSING
2015

+
How do I know it’s right for me?
 Join the APNA or ISPMHN
 Volunteer
 Do some volunteer work in agencies, hospitals, and/or community programs
where you encounter individuals or families with psychiatric problems.
 A “rotation” on a psychiatric-mental health unit helps introduce students to
the specialty and assists them with determining if they want to work in this
area or even pursue a master’s degree in psychiatric-mental health nursing.
http://www.apna.org

+
Psychiatric Nursing Professional Organizations
 American Psychiatric Nurses Association
 Membership available to nursing students $25.00 per year.
 International Society of Psychiatric-Mental Health Nurses
 Associate Membership available to nursing students
$25.00 per year.

+ Psychiatric Nursing
Credentialing
 American Nurses Credentialing Center
 RN-BC Psychiatric – Mental Health Nurse
 PMHNP Psychiatric – Mental Health Nurse Practitioner

+
Why is psychiatric nursing
different?
our patients are not usually confined to their beds
“Walkie Talkies”
Their clinical issues primarily involve thoughts and
feelings
Our nursing interventions focus on managing our
patient’s behavior

+
MENTAL HEALTH MENTAL ILLNESS
Accepts self and others Feelings of inadequacy - Poor self-
concept
Ability to cope or tolerate stress.
Returns to normal functioning if
temporarily disturbed
Inability to cope
- Maladaptive behavior
Ability to form close and lasting
relationships
Inability to establish a meaningful
relationship
Uses sound judgment to make
decisions
Displays poor judgment
Accepts responsibility for actions Irresponsibility or inability to accept
responsibility for actions
Optimistic Pessimistic
http://www.cartercenter.org/resources/pdfs/health/ephti/library/lecture_notes/nursing_students/LN_Psych_Nsg_final.pdf
What are examples of
mental health?

+
Recognizes limitations (abilities and
deficiencies)
Does not recognize limitations (abilities
and deficiencies)
Can function effectively and
independently
Exhibits dependency needs because of
feelings of inadequacy
Able to perceive imagined
circumstances from reality
Inability to perceive reality
Able to develop potential and talents
to fullest extent
Does not recognize potential and
talents due to a poor self-concept
Able to solve problems Avoids problems rather than handling
them or attempting to solve them
mental health?

+
Can delay immediate gratification Desires or demands immediate
gratification
Mental health reflects a person’s
approach to life by communicating
emotions, giving and receiving.
Working alone as well as with other,
accepting authority, displaying a sense
of humor, and coping successfully with
emotional conflict.
Mental illness reflects a person’s
inability to cope with stress,
resulting in disruption,
disorganization, inappropriate
reactions, unacceptable behavior
and the inability to respond
according to his expectations and
the demands of society
mental health?

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 Effective teamwork includes the active participation in
team decision making by all staff, including unlicensed
mental health workers
Difference in treatment
modalities
 Mental health workers are often the
ones who first recognize the need for
intervention

+
Positive feedback can be
effective when communicating
with patients about their
behavior
Difference in tx modalities
Patient are often used to negative
feedback. At times patients will
behave in ways to illicit negative
feedback

+
 Observation in psychiatry has at least two functions --
safety and assessment
 Three types of observation are common in psychiatry:
 unit rounds
 observation of individual patients
 observation of the milieu as a whole
modalities

+
 Help our patients learn effective ways of managing
their own behavior by acquiring skills that will be
critical to their success when they return to the
community
modalities

+
 Reference
Stanton, K., (2014) Psychiatric Nursing. Retrieved 9/6/14
https://nursing.advanceweb.com/CE/TestCenter/Content.aspx?CourseI
D=983&CreditID=1&CC=259047&sid=3415

+ S
Subjective
 Mood
 How did patient cope?
 Exercise
 Medicine taken
 Sleep and appetite
?
?
??

+ Subjective
 Triggers
 Stress at work
 Stress at home
 Lack of sleep
 Negative Self Talk
 Relationship Problem
 Arguing
 Alcohol Consumption
 Poor diet
 Medicine not taken
 Ill health or pain
 Difficult life changes
 Workplace changes
 Change in treatment
 Change in General
 Strategies for Wellness
 Adequate sleep
 Water
 Minimal Caffeine
 Minimal Alcohol
 Professional support
 Social Support
 Routine Day
 Managing Conflict
 Enjoyable activities
 Activities with others
 Time outside
 Positive thinking
 Looking outward

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Suicidal/Homicidal
Ideation
Suicide
“Have you had thoughts that you would be better
off dead, or that life is not worth living, of of
hurting yourself, or ending your life?”
Assess: Plan, Means and Duration
Asking about suicidal ideation does not
increase the risk of an attempt.

+ Suicide Assessment
Five-step Evaluation
and Triage
Identify Risk Factors
Identify Protective Factors
Conduct Suicide Inquiry
Determine Risk Level/Intervention
Document
SAMHSA(2009) HHS Publication No. (SMA)09-4432)

+
Suicide Severity
Information/Trai
ning
Columbia-Suicide Severity Rating Scale (C-SSRS)
Columbia University Medical Center
Center for Suicide Risk Assessment
Available at:
http://www.cssrs.columbia.edu/scales_practice_cssrs.html

+ O
Objective
Mental Exam

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Consciousness
Disturbances of consciousness usually
indicate organic brain impairment
Clouding
Stupor
Lethargy
Coma
Alert
A patient usually
has fluctuations in
the level of
awareness of the
enviornment with
delirium

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Appearance
Items
• Body Type
• Grooming
• Posture
• Clothes
• Hair
• Nales
Terms
• Healthy
• Sick
• Ill at ease
• Poised
• Old looking
• Young
looking
• Disheveled
• Childlike
• Bizarre
SignsofAnxiety
• Moist
hands
• Perspiring
• Tense
posture
• Wringing
hands
• Wide eyes

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Speech
Quality
• Talkative
• Nonverbal
• Unspontaneous
• Normally
responsive to
cues
Rate
• Rapid
• Slow
• Pressured
• Hesitant
Quality
• Emotional
• Dramatic
• Monotonous
• Mumbled
• Whispered
• Slurred

+
Mood/Affect
• Depressed, sad, agitated,
angry, irritable, euphoric,
happy, guilty, hopelessMood
• Flat
• Constricted
• Blunted
• Appropriate or Not?
Affect

+
Mental Status Exam Elements
Available at: http://aitlvideo.uc.edu/aitl/MSE/msekm.swf

+
Thought Process
• Logical
• Coherent
• Incomprehensible
Thought Content
• Ideas
• Beliefs
• Preoccupations
• Obsessions
Abnormal
Delusions
• Grandiose
• Paranoid
• Sexual
Illusions

+
Orientation
Person
• What’s
your
name?
Place
• Do you
know
where
you are?
• What kind
of place is
this?
Time
• Do you
know
what day
it is?
What
season?
What
time it is?
• What year
is it?
Impairment usually appears in this order (i.e., sense of time is
impaired before sense of place); as the patient improves, the
impairment clears in the reverse order.

+
Perception
Halluctionations
Auditory
Visual
Taste
Smell
Tactile
When
falling
asleep
When
waking
up
Stressors
involved
Have you heard voices or other sounds that no one else hears?
Have you experienced any strange sensations in your body that no one else
sees?

+ What is the difference between
a hallucination, delusion and
illusion?
Television
Hallucination
• Watching the
TV when its off
Delusion
• Thinking the
TV is sending
you a message
Illusion
• Thinking
someone you
know is on TV

+
When asked what she would do if she found a stamped, addressed
envelope on the street, the patient replied, “Well I would open it of
course and read what it said. Maybe there would be money in it.”
Does the patient understand
the likely outcome of their
Behavior? Are they influence
by this understanding?
Can the patient imagine what
she would do in imaginary
situations?
Judgement

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Insight
• Complete denial of their illnessPoor
• Some awareness that they are ill, blame
others, external factors or organic factorsFair
• Acknowledge that they have an illness by
ascribe it to something unknown in
themselves
Good
• Admit they are ill and acknowledge that their
failures to adapt are partly because of their own
irrational feelings
Intellectual
Insight

+
Memory
• Repeat “Apple,
table, penny”
Immediate
• What were the
three objects I
asked you to
repeat?
Recent • Where did you
go to school in
3rd grade?
Long Term

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Concentration
World
Serial 7’s
Months
• Spell world
backwards
• Starting with 100
count backwards by
7 (or 3)
• Starting with
December tell me
the months in order
backwards

+ Abstract Thinking
Very Concrete
“Glass can
break easily”
Overly abstract
“houses are a
good thing for
anyone”
What does People who live
in Glass houses should not
throw stones mean?

+
References
 Sadock, B. J., & Sadock, V. A. (2007). Kaplan and Sadock's: Synopsis of
psychiatry (10th ed.). Philadelphia: Lippincott, Williams, & Wilkins.

+
Maryann Ryan, MSN, APN, NP-C, PMHNP-C
Therapeutic
Communication

+
Hildagard Peplau
Known as the mother of psychiatric
nursing, Peplau introduced the "nurse-
patient relationship" idea 40 years ago.
This was at a time when patients did
not actively participate in their own
care.
http://media01.commpartners.com/PCNA/pcna_hilda_peplau.html
Nurse Patient Relationship

+
The nurse-client relationship is the
foundation on which psychiatric
nursing is established.
The therapeutic interpersonal
relationship is the process by which
nurses provide care for clients in
need of psychosocial intervention.

+
Therapeutic
relationships are:
•goal- oriented
•directed at learning
and growth promotion.
•patient is the primary
focus of the interaction

+
Nurses must
possess:
self-
awareness
self-
understanding of
one’s own
•Beliefs
•Thoughts
•Motivations
•Biases
•Limitations
•recognizing how they
affect others.
 Therapeutic Use of Self
The ability to use one’s personality consciously and in full awareness in
an attempt to establish relatedness and to structure nursing
interventions.

+
Requirements for Therapeutic Relationship
Rapport
Trust
Respect
Genuineness
Empathy

+
 In analyzing patient-nurse communication, nonverbal behaviors and
gestures are communicated first. If a patient’s verbal and nonverbal
communications are contradictory, priority should be given to the
nonverbal behavior and gestures.
 TYPES OF COMMUNICATION
Nonverbal
Verbal

+
Communication Types VERBAL
SENDER – Initial message
FEEDBACK
RECEIVER – Replies to message
Ideas into words Interpretation:
Feelings,
connotations
With appropriate emotions
RESENDS
RESENDS

+ Communication Types
NON VERBAL
SUSPICION
DEFENSIVENESS
BOREDOM
OPENESS
EVALUATION
READINESS
A patient’s Non
Verbal
Communication
Is more important
than their verbal
communication

+
Phases of a Therapeutic Nurse-Client Relationship
Orientation/Introductory
Period
Working Termination

+
Nontherapeutic Communication Techniques
Giving reassurance
Rejecting
Approving or disapproving
Agreeing or disagreeing
Using denial
Interpreting
Introducing an unrelated topic

+
Nontherapeutic Communication Techniques
Giving advice
Probing
Defending
Requesting an explanation
Indicating the existence of an external source of power
“not their fault”
Belittling feelings expressed
Making stereotyped comments, clichés, and trite
expressions

+ Example
Non Therapeutic
Communication
http://www.youtube.com/watch?v=ZarN-cEkrRs

+
Therapeutic Communication Techniques
Using silence - allows client to take control of the discussion, if
he or she so desires
Accepting - conveys positive regard
Giving recognition - acknowledging, indicating awareness
Offering self - making oneself available
Giving broad openings - allows client to select the topic

+
Offering general leads - encourages client to continue
Placing the event in time or sequence - clarifies the
relationship of events in time
Making observations - verbalizing what is observed or
perceived
Encouraging description of perceptions - asking client to
verbalize what is being perceived
Encouraging comparison - asking client to compare similarities
and differences in ideas, experiences, or interpersonal
relationships

+
Restating - lets client know whether an expressed
statement has or has not been understood
Reflecting - directs questions or feelings back to client
so that they may be recognized and accepted
Focusing - taking notice of a single idea or even a single
word
Exploring - delving further into a subject, idea,
experience, or relationship
Seeking clarification and validation - striving to explain
what is vague and searching for mutual understanding

+
Presenting reality - clarifying misconceptions that client may
be expressing
Voicing doubt - expressing uncertainty as to the reality of
client’s perception
Verbalizing the implied - putting into words what client has
only implied
Attempting to translate words into feelings - putting into
words the feelings the client has expressed only indirectly
Formulating plan of action - striving to prevent anger or
anxiety escalating to unmanageable level when stressor recurs

+ Example
Therapeutic
Communication
http://www.youtube.com/watch?v=AlFDgEFYcVw

+
Listening to the Patient
Sit squarely facing the client
Observe an open posture
Lean forward toward the client
Establish eye contact
Relax

+
References
 Epstein RM, Borrell F, Caterina M . Communication and mental health in primary care. In New
Oxford Textbook of Psychiatry (Edrs. Gelder MG, López-Ibor JJ, Andreasen NC), Oxford University
Press, 2000.

+
Maryann Ryan, MSN, APN, NP-C, PMHNP-C
Cultural
Considerations
Therapeutic
Communication

+
DID YOU KNOW?
 Writing a persons name in red ink means you are dead in the Korean culture?
 Some Asian cultures may think you are trying to kill them if you offer a cold glass of water?
 IKEA somehow agreed upon the Name “FARTFULL” for one of its new desks?
 Pepsodent tried to sell its toothpaste in southeast Asia by emphasizing that it “whitens your teeth.”
They found out that the local natives chew betel nuts to blacken their teeth, which they find
attractive.
 Kellogg had to rename its Bran Buds cereal in Sweden when it discovered that the name roughly
translated to “Burned farmer”
 When Pepsico advertised Pepsi in Taiwan with the ad “Come Alive With Pepsi” they had no idea
that it would be translated into Chinese as “Pepsi brings your ancestors back from the dead.”
 In Italy, a campaign for Schweppes Tonic Water translated the name into “Schweppes Toilet
Water”.

+
Rule #1 Guard against
perceived similarities
Always observe closely
When we perceive others to be similar to us, we lack the sensitivity
required to see differences that may exist.
Adjust your communication , both verbal and nonverbal, to better
align with individuals in which you are communicating.
Treating people from different cultures the same as we treat others
from our own culture may be inappropriate.
Our perceptions will blind us to cultural differences that we must
adapt to in order to be effective in our communication.

+ Rule #2
Guard against stereotypes
Stereotypes lock us into a way of thinking and treating others in a
certain way.
Stereotypes alter our communication and may cause inappropriate
behaviors.
Stereotypes cause us to behave in a certain way.
When we do this, we are unable to adjust our thinking and are not
able to adjust our our behavior in a manner that would best “fit” the
situation.
Guard against unacceptable behavior that will stifle and hinder the
opportunity to build positive cross cultural relationships.

+
Rule #3 Recognize that Cultural
Differences Exist
Recognize and adapt.
We then are able to monitor our own behavior in relation to what is most
effective cross culturally.
Recognizing that people have different values and belief structures leads to a
better understanding of those differences.
Recognition improves awareness, improved awareness improves our ability to
adjust our behavior.
When we recognize that differences exist, adaptation can be made to improve
communication.
Our ability to recognize cultural differences impacts our communication.

+
Rule #4 Guard Against
Judging Others
Judging impedes health interaction and is unproductive for all.
Judging diminishes our ability to understand and accept differences.
Therefore, take a non-judgemental approch in order to improve
communication.
Judging others locks us into patterns of interaction based on what we
think, in stead of what can be learned about others.
Recognizing cultural differences in adaptive and productive.

+
Rule #5 Describe,
evaluate, adjust
After describing what is around us, we can evaluate our plan
of action.
By describing the culture around us, we begin to extend
ourselves culturally.
By doing so we are more likely to adjust our communication
activities to match those with whom we are communicating.
In order to communicate effectively cross culturally, we must
first describe the culture.
This is part of “figuring things out” before we act in an
unacceptable manner.

+
HIPPA, Privacy,
Confidentiality
and Social Media

+
Gossiping about
something you’ve
overheard is rarely a
good idea in healthcare.

+
Special Considerations in Mental Health
Staff/students are prohibited
from confirming or denying
that a patient is on the
psychiatric unit.
In public, staff/students are
not allowed to acknowledge a
patient. If a patient
approaches staff, it is okay to
engage in an appropriate
conversation.
Engaging in a relationship
with a mental health patient
can put you at risk for a
conflict of interest, even if the
patient initiates the contact.

+
Common Myths and Misunderstandings of Social
Media
A mistaken belief that the communication or post is private
and accessible only to the intended recipient.
A mistaken belief that content that has been deleted from a
site is no longer accessible.

+
How to Avoid Problems
Nurses are strictly prohibited from
transmitting any information that may
be reasonably anticipated to violate
patient rights to confidentiality or
privacy, or otherwise degrade or
embarrass the patient.
Do not refer to patients in a
disparaging manner, even if the
patient is not identified
Do not identify patients by name or
post or publish information that may
lead to the identification of a patient.
Do not take photos or videos of
patients on personal devices,
including cell phones.
Nurses have an ethical
and legal obligation to
maintain patient
privacy and
confidentiality at all
times.

+
How to Avoid Problems
Use caution when having online
social contact with patients or
former patients.
Do not share information given
by patients on line.
The nurse has the obligation to
establish, communicate and enforce
professional boundaries with
patients in the online environment.
The fact that a patient may initiate
contact with the nurse does not
permit the nurse to engage in a
personal relationship with the
patient.
Maintain professional
boundaries in the use of
electronic media

+
Additional Legal
Issues in
Mental Health

+
Determination of Capacity
Assessment Area Definition Patient Attributes
Communicate
choices
Ability to express choices Patient should be able to repeat
what he or she has heard
Understand relevant
information
Capacity to comprehend
the meaning of the
information given about
treatment
Patient should be able to paraphrase
understanding of treatment
Appreciate the
situation and its
consequence
Capacity to grasp what
the information means
specifically to the patient
Patient should be able to discuss the
disorder, the need for treatment, the
likely outcomes, ad the reason the
treatment is being suggested
Use a logical
thought process to
compare the risks
and benefits of
treatment options
Capacity to reach a logical
conclusion consistent
with the starting premise
Patient should be able to discuss
logical reasons for the choice of
treatment

+
Duty to Warn
Health care providers are legally obligated to
breach confidentiality. When there is a judgment
that the patient has harmed any person or is
about to injure someone, professional are
mandated by law to report it to authorities.

+
Involuntary Commitment
Involuntary commitment
 Is the confined hospitalization of a person without the
person’s consent but with a court order. There are three
common elements:
1. Mentally disordered
2. Dangerous to self or others
3. Unable to provide for basic needs “gravely disabled”

+
Least restrictive environment
Least restrictive environment
 An individual cannot be restricted to an institution when
they can be treated in the community.
 Medication cannot be given unnecessarily.
 An individual cannot be restrained or locked in a room
unless ALL other “less restrictive” interventions have been
tried first.

+
Behavioral
Management of
Aggression

+
Management of Agitation and Aggression
•Most patients with mental
disorders are not aggressive.
•Evidence does point to
increased risk for violence
among individuals with a
mental disorder as
compared to the general
population.

+
Anger, Agitation, and Aggression
Anger is the emotional response to a perceived
grievance which may be real or imagined.
Agitation refers to the unpleasant state of arousal
with increased tension and irritability which can lead
to hyperactivity, confusion and outright hostility
The spiral of anger and escalating agitation can lead
to aggressive behavior.

+ What are the risk factors?
History of violence Chemical Withdrawal
Pain Chronic fatigue
Diagnoses
• Delirium
• Dementia
• personality
disorders
• mania
• substance abuse
What is the most important
Risk factor to assess for?
History of violence

Response to internal
stimuli
• Psychosis
• delusions
• hallucinations
Medication issues
• Frequent changes
• Non-compliance
Changes in environment
Long waiting and feelings
that no one is paying to
attention to one’s needs
Psychosocial stressors
• Illness
• Financial
• health concerns
• relationship issues
• feelings of intimidation
and loss of control

Response to internal stimuli
• Psychosis
• delusions
• hallucinations
Medication issues
• Frequent changes
• Non-compliance
Long waiting and feelings that no
one is paying to attention to one’s
needs
Psychosocial stressors
• Illness
• Financial
• health concerns
• relationship issues
• feelings of intimidation and loss
of control

+ Recognize and prevent through
awareness and assessment…
Facial
expressions
• Glaring eyes
• Clenched
teeth
• Red face
Body Stance
• Tensed
muscles
• Clenched
fists
Physiologic
Changes:
• Sweating
• Shallow or
heavy
breathing
• Tremors
Observational cues and behaviors associated
with anxiety/tension

+ Recognize and prevent
through awareness and
assessment…
Speech:
• Loud
• Forceful
• Cursing
• Threatening
• repetitive questions
• Sarcastic
• Challenging
Actions:
• Restlessness
• Pacing
• Fist Pounding
• Refusal to follow
direction
Observational cues and behaviors associated
with anxiety/tension

+
Understand the underlying issues motivating anger
Fear Frustration Feelings of
Intimidation
Feelings of
loss of
control
Feelings of
intolerable
anxiety

+
(Handle with care, 2006)
Management of Agitation and Aggression
ANGER
AGITATION
Interventions
De-escalation
Medication
Increased Anxiety
Tension
Repetitive questions
Pacing
Sweating
breathing patterns
AGRESSION
Verbal/nonviolent
Indirect Passive
complain
blame
resistance
self injury
Direct Assertive
Profanity
Increased Hyperactivity
ASSAULTIVE
BEHAVIOR
VIOLENCE
Direct
Physical threats to self, others,
environment
Direct abusive language
intimation

+
Separate agitated person
from other patients
Allow the patient to see
staff presence
Minimize environmental
stimuli
Maintain a safe distance
• At least two arm’s
length
• Off to the side
Assume a non-
threatening stance
Maintain eye contact
Safety, Safety, Safety…….

+
Aggression and Violence
in Health Care
 Although workplace violence occurs in all work environments,
the health industry is particularly prone, especially in the areas
of behavioral health and emergency departments.
 Nurses and healthcare professionals need to recognize the
behaviors of both the perpetrators and themselves in order to
effectively de-escalate potential patient aggression and
violence.

+
Elements of Supportive Interventions
• Allow person to vent feelingsListen
• And consider the validity of the feelingsAccept
• On one issue at a timeFocus
• AssertivenessEncourage
• Choices that the patient can makeOffer Alternatives
• With and persuade the individual to agree on
course of appropriate action.Contract

+ References
 Chapman, R., Perry, L., Styles, I., & Combs, S. (2009, March). Predicting
patient aggression against nurses in all hospital areas. British Journal of
Nursing, 18, (8) 476, 478 – 83.
 Cowin, L., Davies, R., Berlin, T., Fitzgerald, M, & Hoot, S. (2003). De-
escalating aggression and violence in the mental health setting.
International Journal of Mental Health Nursing, 12 (64-73).
 Handle with Care® (2006). Instructor Manual: Gardiner, NY.
 Rippon, T. J. (2000). Aggression and violence in health care professions.
Journal of Advanced Nursing, 31 (2), 452-460.
 Zernicke, W. (1998). Patient aggression in general hospital setting: do
nurses perceive it to be a problem? International Journal of Nursing
Practice.

+
Safety Tips
 Be aware of your environment
 Always know where the exit is
 Keep your eyes on the patient
 Know your patient: History of violence? Recent threats?
Recent problems with patient on unit? Incarceration?
Command hallucinations?
 Keep more than an arms length between yourself and a
patient
 Call for help if a situation begins to escalate

+ Wrist Grab
Defense
 You have been grabbed by a patient with a
same sided wrist grab (their right hand on
your right wrist or visa versa)
Step 1 Make fist and twist to person’s thumb
and fingers
Step 2 Opposite Leg – Step back
Step 3 Grab your fist with your other hand
Step 4 Snap back – Pull your fist back and
transfer weight to opposite leg.
Why? This gets you away from the attacker

+ Two handed Wrist
Grab Defense
 Your attacker has grabbed both of your wrists
Step 1: Make two fists
Step 2: Roll wrists inwards, place one foot behind you
Step 3: Snap back, pull your wrists to your chest at the same time you
step back

+ Choke hold
defense
Your attacker has grabbed both of your wrists
Step 1 Protect your airway, tuck your chin at the bend of
the elbow of the
Attacker.
Step 2 Please your hand under the elbow like holding a
pizza tray
Place your other hand over your attackers hands
Sept 3 Push up on your attackers elbow and twist
downward
And to the side at the same time

+ Hair pulling
defense
 Your attacker is pulling your hair
Step 1 Place your hands on top
Of the attackers hands and
Press against your head firmly
Step 2 Start to lower your head to
Put pressure on their wrist

+ Bite defense
An Attacker is biting you
Step 1 hold head to your body
Don’t pull away
Step 2 Use the side of your hand
To push up under the attacker’s nose

+ Appendix I
Mnemonics
http://www.currentpsychiatry.com/home/article/mnemonics-in-a-mnutshell-32-aids-to-psychiatric-diagnosis/ce6ce4b6b4429382a239bf4db99000c2.html

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Appendix II
Bill of Rights for Persons Receiving Mental Health Services
• The right to treatment and services under conditions that
support the person’s personal liberty and restrict such
liberty only as necessary to comply with treatment needs,
laws, and judicial orders.
• The right to be an individualized, written, treatment or
service plan (to be developed promptly after admission),
treatment based on the plan, periodic review and
reassessment of needs ad appropriate revisions of the plan,
including a description of services that may be needed after
discharge.
• The right to ongoing participation in the planning of
services to be provided and in the development and
periodic revision of the treatment plan, and the right to be
provided with a reasonable explanation of all aspects of
one’s own condition and treatment.
• The right not to participate in experimentation in the
absence of the patient’s informed, voluntary, written
consent, the right to appropriate protections associated
with such participation, the right to an opportunity to
revoke such consent.
• The right to freedom from restraints or seclusion, other
than during an emergency situation.
• The right to a humane treatment environment that affords
reasonable protection from harm and appropriate privacy.
• The right to confidentiality of records.
• The right to access, upon request, one’s own mental health
care records.
• The right (in residential or inpatient care) to converse with
others privately and to have access to the telephone and
mails, unless denial of access is documented as necessary
for treatment.
• The right to be informed promptly, in appropriate language
and terms, of the rights described in this section.
• The right to assert grievances with respect to infringement
of the Bill of Rights, including the right to have such
grievances, considered in a fair, timely, and impartial
procedure.
• The right of access to protection, service and a qualified
advocate in order to understand, exercise , and protect
one’s rights.
• The right to exercise the rights described in this section
without reprisal, including reprisal in the form of denial of
any appropriate, available treatment.
• The right to referral as appropriate to other providers of
mental health services upon discharge.
From Title V of the Mental Health Systems Act [42 U.S.C. 9501 et seq.] Retrieved from
http://www4.law.cornell.edu/uscode/42/10841.html

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Appendix III
Labs to look for
Depakote Ammonia Level, plattlets, level
Clozaril, Seroquel CBC
Tegretol, Trileptal Sodium
Lithium Kidney Function, Thyroid Function
Aricept Bradicardia
All Second Generation
Antipsychotics
QTc interval

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