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Mental Health

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Mental Health Nursing

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Mental Health

  1. 1. Unit 1 Course Introduction Mental Health and Illness Legal/Ethical Professional Standards
  2. 2. Qualities of Mentally Healthy Person <ul><li>Relative happiness </li></ul><ul><li>Self control </li></ul><ul><li>Reality orientation </li></ul><ul><li>Effective at work and social roles </li></ul><ul><li>Accurate self concept (locus of control, self esteem) </li></ul>
  3. 3. DSM IV Diagnostic and Statistical Manual <ul><li>Axis I: Major mental disorder </li></ul><ul><li>Axis II: Personality disorder/mental retardation </li></ul><ul><li>Axis III: General Medical Conditions </li></ul><ul><li>Axis IV: Psychosocial/Environmental factors affecting the situation </li></ul><ul><li>Axis V: Global Assessment of Functioning Scale (GAF) </li></ul>
  4. 4. Professional Standards <ul><li>ANA Standards from Cover of Text </li></ul><ul><li>Patient Care Standards </li></ul><ul><li>Rationale for Standards </li></ul><ul><li>RN responsibility-how it fits with legal and ethical aspects of the profession </li></ul>
  5. 5. Ethical Positions <ul><li>Beneficence: duty to do what is of benefit to others </li></ul><ul><li>Autonomy: Right to self determine choices affecting oneself </li></ul><ul><li>Justice: right to fair treatment </li></ul><ul><li>Fidelity (non maleficence):doing no wrong to client, acting with loyalty </li></ul>
  6. 6. Patient’s Bill of Rights <ul><li>Maintain civil rights: vote, contracts, religious </li></ul><ul><li>Client consent: refuse treatment, grievance </li></ul><ul><li>Communication: mail and phone/full and private </li></ul><ul><li>Freedom from harm: unnecessary restraint, isolation, medication </li></ul><ul><li>Dignity/respect </li></ul><ul><li>Confidentiality: both written (libel) and oral (slander) </li></ul><ul><li>Participation in care plan </li></ul>
  7. 7. Other legal points of interest <ul><li>Parens patriae: state as “parent” </li></ul><ul><li>Police power:right of state to protect society </li></ul><ul><li>Least restrictive alternative—guiding principle in mental health </li></ul><ul><li>Tarasoff decision—duty to warn </li></ul>
  8. 8. Voluntary Admission <ul><li>Signs self in, needs order, may be instead of involuntary admit. </li></ul><ul><li>For insurance to pay, often must show major mental illness, dangerousness, inability to manage as outpatient, start of Rx requiring close supervision </li></ul><ul><li>If requests d/c prematurely may get: regular d/c, AMA, or commitment petition filed. </li></ul>
  9. 9. Involuntary Admission <ul><li>If police bring in—called IDO immediate detention order, requires exam then decision re status </li></ul><ul><li>EDO—emergency detention order, signed by qualified medical personnel (ie MD). To court in 72 hours for decision. </li></ul><ul><li>If the decision is to commit at this time, it is called a temporary commitment (90 + 90). This decision is based on four criteria. </li></ul><ul><li>After 90 + 90 can be placed on indefinite commitment with a yearly review. </li></ul>
  10. 10. Types of Therapeutic Approaches (review!) <ul><li>Psychoanalytic </li></ul><ul><li>Rational Emotive Therapy </li></ul><ul><li>Cognitive Therapy </li></ul><ul><li>Behavioral Therapy </li></ul><ul><li>Milieu Therapy </li></ul><ul><li>Group Therapy </li></ul><ul><li>Medical/biologic therapy </li></ul>
  11. 11. Stages of Therapeutic Relationship <ul><li>1. Preorientation; prep, values clarification, history </li></ul><ul><li>2. Orientation: establish trust, boundaries, and client contract </li></ul><ul><li>3. Working: deal with problems and changing behavior </li></ul><ul><li>4. Termination: discuss progress, referral, say good bye </li></ul>
  12. 12. Refresh yourself regarding: <ul><li>HIPAA </li></ul><ul><li>Professional Dress </li></ul><ul><li>Know where to go for your clinical </li></ul>
  13. 13. Unit 2 Communication and Assessment Therapeutic communication Dealing with Upset people Anxiety levels, Mental Mechanisms Intro to assessment
  14. 14. Review of Communication Issues <ul><li>Content and Process in a verbal message </li></ul><ul><li>Congruent and Incongruent communication </li></ul><ul><li>Therapeutic use of self </li></ul><ul><li>Differentiate transference and counter-transference </li></ul><ul><li>Positive regard </li></ul><ul><li>Empathy versus sympathy </li></ul>
  15. 15. Therapeutic approaches <ul><li>Accepting, recognizing </li></ul><ul><li>Offering self </li></ul><ul><li>Broad openings and general leads </li></ul><ul><li>Restating and reflecting </li></ul><ul><li>Encouraging comparison and description of perception </li></ul><ul><li>Making observations </li></ul><ul><li>Focusing </li></ul><ul><li>Exploring </li></ul><ul><li>Seeking clarification </li></ul><ul><li>Presenting reality </li></ul><ul><li>Voicing doubt </li></ul><ul><li>Verbalizing the implied </li></ul><ul><li>Encouraging formulation of a plan of action </li></ul>
  16. 16. Non therapeutic approaches and common errors <ul><li>False reassurance </li></ul><ul><li>Agreeing/disagreeing </li></ul><ul><li>Giving advice </li></ul><ul><li>Probing </li></ul><ul><li>Defending </li></ul><ul><li>Asking why </li></ul><ul><li>Belitting feelings </li></ul><ul><li>Using denial </li></ul><ul><li>Interpreting </li></ul><ul><li>Changing the subject </li></ul><ul><li>Rejecting </li></ul><ul><li>Repetitive closed questions </li></ul><ul><li>Body language indicates hurry or frustration </li></ul><ul><li>“ Is there anything you want to talk about?” </li></ul>
  17. 17. Fight or Flight <ul><li>Fight </li></ul><ul><li>Responds to stress, threat and uncertainty with conflict, anger, violence </li></ul><ul><li>Review Symptoms of Fight or Flight Response! </li></ul><ul><li>Flight </li></ul><ul><li>Responds to stress, threat, and uncertainty with anxiety, fear, etc </li></ul>
  18. 18. Dealing with an Upset Person <ul><li>Body language: Calm, warm, open posture at a side angle. Good eye contact, no staring. </li></ul><ul><li>Voice tone: Assertive, audible, calm, low, slow. </li></ul><ul><li>Keep verbal responses short and simple. </li></ul><ul><li>Your response should match their behavior—they talk, you talk; they act; you act. </li></ul><ul><li>Give choice between 2 acceptable options </li></ul>
  19. 19. Conflict Management and Anger <ul><li>Anger is a problem if it explodes out uncontrollably or if it is held in excessively </li></ul><ul><li>Staff and clients both have anger issues </li></ul><ul><li>Often anger leaks out in subtle ways: sarcasm, excessive humor, making people wait, silent treatment, physical ailments, overly polite behavior, crying, acting superior </li></ul>
  20. 20. Styles of Conflict Management—Which fit you the best? <ul><li>Forcing—I win, you lose </li></ul><ul><li>Confronting—Care enough to be honest </li></ul><ul><li>Compromising—Both partly win </li></ul><ul><li>Smoothing—I give in to make you feel better </li></ul><ul><li>Withdrawing—Anger is too scary to face, I withdraw </li></ul>
  21. 21. General Tips for Conflict Management <ul><li>Realize that anger is a normal emotion, discover what the anger is about! </li></ul><ul><li>Find out/ask for what you need </li></ul><ul><li>Deal with the person you are angry with </li></ul><ul><li>Each person is responsible for his/her own behavior </li></ul><ul><li>Think before you speak </li></ul>
  22. 22. More General Tips… <ul><li>What are the implications of fighting this battle? Worth it? </li></ul><ul><li>Respect for the person is vital </li></ul><ul><li>If you have a complaint, bring a solution to the table. Don’t just bring problems… </li></ul><ul><li>Bring everyone who has a real stake in the issue together to deal with it. </li></ul>
  23. 23. Peplau’s Mild Anxiety <ul><li>Increased ability to perceive, heightened senses </li></ul><ul><li>Effectively learn, work toward goal, good awareness </li></ul><ul><li>Slight restlessness, mild tension </li></ul><ul><li>No intervention needed </li></ul>
  24. 24. Peplau’s Moderate Anxiety <ul><li>Narrowed perceptual field, sees less of what is going on—selective inattention </li></ul><ul><li>Able to do some problem solving with help </li></ul><ul><li>Shaky voice, less concentration, headache, insomnia, pacing, some minor fight or flight symptoms </li></ul>
  25. 25. Interventions for Moderate Anxiety <ul><li>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.” </li></ul><ul><li>Cognitive reframing </li></ul><ul><li>Teaching </li></ul><ul><li>Anxiety reduction techniques – relaxation training, meditation, counting, deep breathing </li></ul>
  26. 26. Peplau’s Severe Anxiety <ul><li>Small perceptual field, attend to irrelevant detail or scattered thoughts </li></ul><ul><li>Self absorbed, feedback doesn’t help much </li></ul><ul><li>Impending dread/doom, purposeless activity, hypervent, tachy, loud rapid speech </li></ul><ul><li>Can’t effectively problem solve or see connections </li></ul>
  27. 27. Peplau’s Panic level of Anxiety <ul><li>Terror and emotional paralysis, hallucinations or delusions take place of reality </li></ul><ul><li>Mute or extreme agitation, irrational, hypervigilant, hyperactive </li></ul><ul><li>Sleepless, not eating, all fight or flight in place </li></ul>
  28. 28. Interventions for all levels of Anxiety <ul><li>Maintain your presence </li></ul><ul><li>Decrease environmental stimuli </li></ul><ul><li>Remain calm </li></ul><ul><li>Speak slowly, clearly, simply </li></ul><ul><li>Base further intervention on level of anxiety and situation </li></ul>
  29. 29. Interventions for Severe or Panic Anxiety <ul><li>Medication—anti-anxiety or anti-psychotic </li></ul><ul><li>Provide short, firm concrete directions to assist the client to calm </li></ul><ul><li>Protect the client from self injury, either intentional or related to inattention or poor reality testing </li></ul><ul><li>Protect the milieu from disruption and injury—discuss </li></ul>
  30. 30. Criteria for Restraint and Seclusion <ul><li>Client imminently harmful to self or others </li></ul><ul><li>Client endangering facility </li></ul><ul><li>Less restrictive measures are not satisfactory </li></ul><ul><li>Client request (rare) </li></ul><ul><li>Must show that criteria were met in your documentation or be at risk for false imprisonment </li></ul>
  31. 31. Proper Restraint/Seclusion order includes: <ul><li>Type of restraint or seclusion (discuss) </li></ul><ul><li>Reason (from frame earlier) </li></ul><ul><li>Specific time limits (agency and state boundaries apply). NO PRN order. </li></ul><ul><li>MD signature. Agency may specify that MD see the client within a certain time frame. </li></ul>
  32. 32. RN Care Issues in R/S: <ul><li>Frequent checks or constant observation, documented (aid can do). </li></ul><ul><li>Protect client privacy; hygiene, ROM, body alignment (discuss frequency). </li></ul><ul><li>Safe/secure application of restraints (will hold ct, applied correctly). Assess circulation, abrasion, alignment, warmth, no harmful objects in area. </li></ul><ul><li>Nutrition, fluid, elimination needs Q2hr </li></ul><ul><li>Reasonable release criteria set, moniter progress towards release at least Q2hr </li></ul>
  33. 33. Issues with R/S <ul><li>Assault: verbal threat, namecalling </li></ul><ul><li>Battery: physical abuse, harm, unwelcome contact </li></ul><ul><li>False imprisonment: habeas corpus </li></ul><ul><li>Can medicate against will only in case of imminent risk of violence to self or others, otherwise not (discuss court order exception) </li></ul>
  34. 34. Other considerations… <ul><li>Get uninvolved clients out of the way </li></ul><ul><li>One person does the talking with client </li></ul><ul><li>Do not attempt to be a hero, always have adequate help before intervening </li></ul><ul><li>Once a limit has been set, it should not be negotiated, sends message that fosters acting out. </li></ul><ul><li>Least restrictive alternative </li></ul>
  35. 35. Defense Mechanisms (ch 13) <ul><li>On a continuum of relative maturity: mature-neurotic-immature-psychotic </li></ul><ul><li>All serve to protect the human from perceived threats (conflict, shame, fear, anger) </li></ul><ul><li>Relatively unconscious, though we can become aware of them </li></ul>

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