Ramapo work shop_sept_2015

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Maryann Ryan, MSN, APN, NP-C, PMHNP-BCRamapo 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?

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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



+


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



+

Teamwork 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

+

Thoughtful communicationPositive feedback can be effective when communicating with patients about their behavior

Difference in tx modalities

Thoughtful communicationPatient are often used to negative feedback. At times patients will behave in ways to illicit negative feedback

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Methodical observation 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


+

Supportive interventions 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


+

Reference

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

+ S

Subjective

Mood How did patient cope? Exercise Medicine taken Sleep and appetite

?? ??

Maryann Ryan, MSN, APN, NP-C, PMHNP-BC

+ 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

+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

ningColumbia-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


+ Consciousness

Disturbances of consciousness usually indicate organic brain impairment

Clouding

Stupor

LethargyComa

Alert A patient usually has fluctuations in the level of awareness of the enviornment with delirium

+ Appearance

Items

•Body Type•Grooming•Posture•Clothes•Hair•Nales

Ter

ms

•Healthy•Sick•Ill at ease•Poised•Old looking•Young looking•Disheveled•Childlike•Bizarre

Sig

ns of A

nxiety

•Moist hands•Perspiring•Tense posture•Wringing hands•Wide eyes

+ Speech

Qu

ality

•Talkative•Nonverbal•Unspontaneous•Normally responsive to cues

Rate

•Rapid •Slow•Pressured•Hesitant

Qu

ality

•Emotional•Dramatic•Monotonous•Mumbled•Whispered•Slurred

+ Mood/Affect

Mood•Depressed, sad, agitated, angry, irritable, euphoric, happy, guilty, hopeless

Affect•Flat•Constricted•Blunted•Appropriate or Not?

+

Mental Status Exam Elements

Available at: http://aitlvideo.uc.edu/aitl/MSE/msekm.swf

http://aitlvideo.uc.edu/aitl/MSE/msekm.swf

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Thought Process

• Logical• Coherent• Incomprehensible

Thought Content

• Ideas• Beliefs• Preoccupations• Obsessions

AbnormalDelusions• Grandiose• Paranoid• SexualIllusions

+ Orientation

Pers

on • What’s your name? Pl

ace • Do you

know where you are?

• What kind of place is this?

Tim

e • 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

HalluctionationsAuditory

VisualTasteSmell Tactile

When falling asleepWhen 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

+ 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

+ 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

+

Read this Sentence.

+ 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?

+ Write a sentence

+

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

http://media01.commpartners.com/PCNA/pcna_hilda_peplau.html

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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.

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Therapeutic relationships are:• goal- oriented • directed at learning

and growth promotion.

• patient is the primary focus of the interaction

+

Nurses must possess:

self-awareness

• 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

+

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

RESENDSRESENDS

+ Communication Types NON VERBAL

SUSPICION

DEFENSIVENESS

BOREDOM

OPENESS

EVALUATION

READINESS

A patient’s Non VerbalCommunicationIs more important than their verbal communication

+

Phases of a Therapeutic Nurse-Client Relationship

Orientation/Introductor

y PeriodWorking Termination

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Nontherapeutic Communication Techniques

Giving reassurance

Rejecting

Approving or disapproving

Agreeing or disagreeing

Using denial

Interpreting

Introducing an unrelated topic

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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

http://www.youtube.com/watch?v=ZarN-cEkrRs

http://www.youtube.com/watch?v=Zarn-cEkrRs

+

Therapeutic Communication Techniques

+


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

http://www.youtube.com/watch?v=AlFDgEFYcVw

http://www.youtube.com/watch?v=A1FDgEFYcVw

+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 #2Guard 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 disordered2. Dangerous to self or others3. Unable to provide for basic needs “gravely disabled”

+Least restrictive environment

Least restrictive environmentAn 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

+ What are the risk factors?

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

+ What are the risk factors?

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

InterventionsDe-escalation

Medication

Increased AnxietyTension

Repetitive questionsPacing

Sweating breathing patterns

AGRESSION Verbal/nonviolent

Indirect Passive complain

blame resistance self injury

Direct AssertiveProfanity

Increased Hyperactivity

ASSAULTIVE BEHAVIOR VIOLENCE

DirectPhysical threats to self, others,

environmentDirect 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 bodyDon’t pull away

Step 2 Use the side of your handTo push up under the attacker’s nose

+ Appendix IMnemonics

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









+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

+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

Education

Ramapo work shop_sept_2015