Upload
gyles-little
View
229
Download
1
Embed Size (px)
Citation preview
Current Theories and Practice
Foundations of Psychiatric–Mental Health
Nursing
Learning Outcomes
• Define the characteristics of mental health and mental illness.
• Discuss the purpose and use of the DSM-IV-TR.• Identify important historical landmarks in
psychiatric care.• Discuss the ANA standards of practice for
psychiatric-mental health nursing.• Describe common student concerns about
psychiatric nursing.
Mental Health
• WHO definition: state of complete physical, mental, and social wellness, not merely absence of disease or infirmity
• Emotional, psychological, and social wellness evidenced by:
– Satisfying interpersonal relationships
– Effective behavior and coping as culture states
– A positive self-concept (self-esteem)
– Emotional stability
Factors Influencing a Person’s Mental Health
• Individual factors– Person traits, Bio Makeup, self-esteem, capacity for growth,
sense of belonging, now you can manage life.
• Interpersonal factors– Relationship traits, communication effectiveness, are you able
to handle intimacy, to act as an individual
• Social/cultural factors– Environmental factors- do you know what’s going on outside
of yourself and your tolerance of it; what’s going on around you; can you go to the store, job, school
– Have a realistic view of the world (war, healthcare, news, etc.)– Understand what’s going on w/ others around you.
Mental Illnessa life long struggle
• Historically- thought to be demon possessed or was being “punished” by a higher power.
• Today- Better understanding that it is a disease. Usually due to chemical imbalances.
Mental Illness (cont’d)
• Mental disorder is “a clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with distress or disability or with a significantly increased risk of suffering death, pain, disability, or an important loss of freedom” (APA)
• Can they distinguish reality from fantasy• Can they communicate• Are they withdrawn• Are they homeless/poverty/lack resources• Can they have relationships
• The DSM-IV-TR® is published by APA and used by mental health professionals to describe all mental disorders according to specific diagnostic criteria– Classifies by axis
• The DSM-IV-TR is a multiaxial classification system
Manual of Mental Disorders
Axis I: Major psychiatric disorders except mental retardation and personality disorders The reason they were brought to the unit: depression, bipolar,
schizophrenia, major depressive disorder recurrent (The reason they’re there)
Axis II: Mental retardation, personality disorders Personality disorders, may or may not have
Axis III: Medical conditions DM, CHF, UTI, FM, meds are affected
Axis IV: Psychosocial and environmental problems Stressors of life: homeless, jobless, divorced, legal problems
Axis V: Global Assessment of Functioning (GAF) score GAF- measures disorder severity; Scale is 0-100 (<30 is
severe) a person can have 2 GAF scores
Where they are at right now 2nd is avg from previous times
Done on assessment, during treatment, on D/C Helps find appropriate care, meds, social work, class, TX
DSM-IV-TR (cont’d) pg 154Look at pts holistically
DSM-IV-TR (cont’d) pg 154Look at pts holistically
#1
[]=‘’’|’’’|’’’|>----
Four is “the box”
5 = GAF
2
Historical Perspective
• Period of Enlightenment– Start of asylums (safe place for “ill” pts)
• Period of Scientific Study– Psycho analysis, talk about feelings, info, education, to study
Mental Illness• Period of Psychotropic Drugs
– Drugs came out to treat (Lithium, Thorazine, etc.)• Thorazine- antipsychotic effects
• Period of Community Mental Health (1963)– Deinstitutionalization- based on Community Mental Health
Act- Pt allowed benefits & released back to Community.• Period of the Brain
– Focus care on pt needs, what pt wanted and not what we “think” they want.
Mental Illness in the 21st Century
• Over 26% of Americans age 18 and older have a diagnosable mental disorder: approximately 57.7 million persons diagnosed each year (NIMH, 2006)
• Hospital stays shorter, more numerous: revolving door D/C too soon
400% increase in ER visits
• Increased aggression among mentally ill clients
• More people with mental illness are incarcerated– 15% or more prisoners have Mental Illness
Mental Illness in the 21st Century (cont’d)
• Homeless population of persons with mental illness is growing (1/3 of homeless have Mental Illness)
• Most healthcare dollars still spent on inpatient psychiatric care; community services not adequately funded
• Healthy People 2010 Mental Health Objectives
(p.8 Box.1.1)
Mental Illness in the 21st Century (cont’d)
• Community-based care– Support service, housing, Case management. (anything outside of
the hospital) Tx usually occurs out in the community.
• Cost containment – Managed care, provider’s services. Most $ goes to Acute care,
General care, Tx, days in, No insurance (Mental health not considered illness).
• Cultural considerations– Because of diversity giving care has become more challenging
– Different beliefs (ex: about why they are ill)
Psychiatric Nursing Practice determines what is safe & acceptable
• Standards of Psychiatric-Mental Health
Clinical Nursing Practice: this outlines areas of concern and standards of care for mental health nurse (p.11-12)
• Psychiatric Mental Health Nursing
Phenomena of Concern: 12 areas of concern that mental health nurses focus on when caring for patients (p.10)
No test Q’s
Student Concerns
• Saying the wrong thing• What student will be doing• Fear of no one talking to student• Bizarre or inappropriate behavior• Physical safety• Seeing someone known to the
student
Self-Awareness Issues
- Everyone has values, beliefs, ideas; nurses need to know what theirs are, not to change them, but to prevent unknown or undue influence on their nursing practice
- Hints to increase self-awareness: keep a journal, talk to trusted coworkers, examine points of other than one’s own view
Treatment Settings and Therapeutic Programs
Learning Outcomes
• Describe different types of treatment settings and the services they provide.
• Identify barriers to effective treatment for special populations with mental illness.
• Describe the roles of different members of the multidisciplinary mental health care team
• Identify the nurse’s roles in treatment settings
Mental Health Settings
• Inpatient setting-acute inpatient hospitals, where stabilize patient and dismiss patient back to community
• Community setting-mental health care conducted in clinics, rehabilitation programs, crisis centers, ACT,etc.
Inpatient Hospital Treatment
In the 1990’s, managed care shortened hospital stays; people were sicker when admitted and were discharged sooner, rendering milieu therapy and “talk” therapy ineffective
Inpatient Hospital Treatment
• Rapid assessment, stabilization, and discharge planning
• Patient-centered focus on keeping pt safe and stable, involve pt in pt care
• Multidisciplinary- Social workers, Psychiatric nurse, Psychiatric social worker, Occupational therapist, Recreational therapist, Psychiatrist
Inpatient Hospital Treatment Includes
• Scheduled inpatient stays- (Med changes or diff treatment) not doing well, just coming in trying to fix problem
• Long-stay patients- Come in for legal reasons, make sure they can stand trial. Mandated by law. (30-90 days for evaluation)
• Case management- starts from the time that they are admitted to D/C. Does the pt have any transportation needs. Check what kind of services are the clients eligible for.
• Discharge planning- the better the D/C planning the longer the pt will thrive in society.
Case Management
• Liaison between the patient and community resources, home care, and third party payers
• Access needed medical and psychiatric services, including help in carrying out tasks of daily living such as using public transportation, managing money, and buying groceries
pg68
Discharge Planning
• Effective discharge planning is crucial b/c of prolapse (ask: Do they have a place/home to go to?)
• Barriers to effective discharge planning include:
– Alcohol and drug abuse
– Criminal or violent behavior
– Noncompliance with medications
• Suicidal ideation
Discharge Planning (cont’d)
Keys to successful discharge planning:
• Staff communication• Patient outpatient program visits• Family involvement (present or not)
– important for successful outcome
• Services geared toward survival in the community and rehabilitation compliance
• Housing and transportation for patient– #1 important key to D/C planning
Partial Hospitalization ProgramsCome to the unit during the day and go home at night.
2-3wks ~duration
Transition to independent community living by:
– Focusing on stabilizing psychiatric symptoms
– Monitoring drug effectiveness
– Stabilizing living environment
– Improving activities of daily living
– Learning to structure time
– Obtaining meaningful work
– Providing follow-up for health concerns
pg69
Residential SettingsLong term, keep in mind limited $$$
• Vary according to the level of supervision, structure, and services provided, as well as the intent of the services
• Types of residential services include:
– Board and care homes- pt come and go
– Adult foster homes- family takes them in; making sure they get to school and have meals
– Halfway houses- places where offenders work and pay rent while undergoing counseling
– Supervised apartment living- minor/no monitoring
– Group homes- helps multiple people function as a unit.
Rehabilitation Treatment Programs
• Emphasize on recovery (30day or more to Tx)
• Reintegration into the community
• Empowerment, increased independence
• Gained an improved quality of life
• Recovery- still have illness, but is sxm free
• Cure- absence of illness altogether
• Rehab Tx- ex: for ETHOL, substance abuse
Assertive Community Treatment• ACT- community based treatment
– offering outreach services: (24/7 MHMR)
• Med Monitoring
• Make Dr’s appointments
• ACT programs involve:
– A problem-solving orientation; no problem is too small
– Direct provision of service rather than referral
– One prob is not having enough staff for everyone
Assertive Community Treatment (cont’d)
• Intensity (3 or more face-to-face contacts per week)
• A team approach rather than having one assigned case manager
• A long-term commitment for as long as the patient needs services
Special Populations
• Homeless
– When compared with homeless persons who are not mentally ill, the homeless mentally ill:
• Spend more time in jail
• Are homeless longer
• Spend more time in shelters
• Have less family contact
• Face greater barriers to employment
Special Populations (cont’d)
• Prisoners
– Up to 15% of persons in jail or prison have severe mental illness
• Criminalization of mental illness refers to prosecuting mentally ill offenders, even for misdemeanors, at a rate four times that of the general population in an effort to contain them in some type of institution
Special Populations (cont’d)
• Criminalization of mental illness is fueled by:
– Increasing public concern that mentally ill persons are violent (though higher chance of person hurting themselves)
– More stringent “harsh” commitment laws
– Lack of community support
– Deinstitutionalization
Interdisciplinary Team
• A multidisciplinary or interdisciplinary team involves the collaboration of a variety of disciplines to provide the most comprehensive, effective services for patients
pg74
Interdisciplinary Team (cont’d)
• Each member makes a unique contribution
– Psychiatric nurse
– Psychiatric social worker
– Occupational therapist
– Recreational therapist
– Psychiatrist
Self-Awareness Issues
• Evolution of care away from inpatient settings into community
• Nontraditional settings such as jails or homeless shelters
• Empowering patients to make their own decisions
• Frustration of working with patients who have persistent and severe mental illness
pg75