NUR 201 MODULE C

1. NUR 201MODULE C INTRODUCTION TO MENTAL HEALTH CONCEPTS AND ISSUES

2. MENTAL HEALTH VS. MENTAL ILLNESS • The concepts of mental health and mental illness are culturally defined. • Individuals experience both physical and psychological responses to stress.

3. Maslow identified: A “hierarchy of needs” Self-actualization as fulfillment of one’s highest potential Defined as “The successful adaptation to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms.” MENTAL HEALTH

4. MENTAL ILLNESS • Defined as “Maladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with the local and cultural norms and interfere with the individual’s social, occupational, or physical functioning.”

5. MENTAL ILLNESS (cont) • Horwitz describes cultural influences that affect how individuals view mental illness. These include: • Incomprehensibility • Cultural relativity

6. PHYSICAL RESPONSE • Hans Selye defined stress as “the state manifested by a specific syndrome which consists of all the nonspecifically induced changes within a biologic system.” • Selye’s General Adaptation Syndrome • The Fight-or-Flight Syndrome • Sustained physical responses to stress promote susceptibility to diseases of adaptation

7. PSYCHOLOGICAL RESPONSES • Anxiety and grief • A variety of thoughts, feelings, and behaviors • Adaptation

8. PSYCHOLOGICAL RESPONSES (CONT.) • Peplau’s four levels of anxiety • Mild- seldom a problem • Moderate - perceptual field diminishes • Severe - perceptual field is so diminished that concentration centers on one detail only or on many extraneous details • Panic - the most intense state

9. PSYCHOLOGICAL RESPONSES (CONT.) • Behavioral adaptation responses to anxiety: • At the mild level • At the mild to moderate level

10. PSYCHOLOGICAL RESPONSES (CONT.) • defense mechanisms • Compensation • Denial • Displacement • Identification • Intellectualization • Introjection • Isolation • Projection • Rationalization • Reaction formation • Regression • Repression • Sublimation • Suppression • Undoing

11. PSYCHOLOGICAL RESPONSES (cont) • Anxiety at the moderate to severe level • Extended periods of functioning at the panic level of anxiety

12. PSYCHOLOGICAL RESPONSES (CONT.) Grief • The subjective state of emotional, physical, and social responses to the loss of a valued entity; the loss may be real or perceived. • Elisabeth Kübler-Ross • (5 Stages of Grief) • Maladaptive grief responses

13. MENTAL ILLNESS THROUGH THE AGES • EVIL SPIRITS; DEMONS • WILDERNESS TO FEND FOR THEMSELVES • “RATIONAL THEORIES” OF GREEKS • DEMONS; LUNACY • SUPERTITIONS, WITCHES, BURNING • LUNATIC ASYLUM • BRAIN DISORDER VS DEMONS • CRUEL, HARSH TREATMENT

14. EMERGENCE OF MENTAL HEALTH • PHILIPPE PINEL • DOROTHEA DIX • DR. BENJAMIN RUSH • CLIFFORD BEERS

15. IMPACT OF WW’s I & II • Need for mental health services • National Committee for Mental Hygiene in 1917 • National Mental Health act 1946 • Funds for research, training and treatment for mental illness

16. PSYCHOTHERAPEUTIC DRUGS • Drugs affecting the mind • Alters emotions, perceptions, consciousness • Psychopharmacologic agents, psychoactive, psychotropic • Lithium carbonate in 1949 • Thorazine in 1956 • Imipramine • Late 50’s/early 60’s antianxiety (Valium)

17. DEINSTITUTIONALIZATION • 1950’s half of hospital beds in U. S. were psych beds • Psychotherapeutic drugs assisted people in controlling behavior • Persons were then discharged from mental institutions • Least restrictive alternative

18. COMMUNITY MENTAL HEALTH CENTER • 1961 Joint Commission on Mental Health • 1963 Congress passed Community Mental Health Centers Act • 1965 Medicare/Medicaid bill • Along with Mental Health Centers act • 75% of institutionalized persons were discharged • Communities not ready • 1970s funding cut • 1975 Congress passed amendments for funding community mental health centers

19. OMNIBUS BUDGET RECONCILIATION ACT • 1981 • Repealed Mental Health System Act • Block grant funding – each state received a designated amount of money • Many states not committed to mental health

20. OMNIBUS BUDGET REFORM ACT • 1987 • Decrease inappropriate placement of chronically mentally ill • Persons discharged from nursing homes etc sometimes “to the streets.” • Funding for mental health care has continued to decrease

21. INPATIENT PSYCH CARE • SAFE ENVIRONMENT • FOCUSES ON WORKING WITH PROBLEMS • CONTINUED EMOTIONAL SUPPORT • INTENSIVE INPATIENT THERAPY • MONITORING TREATMENT, MEDICATIONS • OPPORTUNITIES FOR RESOLVING INTERPERSONAL ISSUES • NEW COPING SKILLS TRIED • DETOX FROM CHEMICALS

22. OUTPATIENT CARE • ALLOWS MENTALLY ILL PERSONS TO LIVE AND WORK WITHIN THEIR OWN COMMUNITIES WITHIN A “LEAST RESTRICTIVE SETTING”

23. MENTAL HEALTH ADMISSIONS • VOLUNTARY—CLIENT ORIGINATES OR AGREES WITH • INVOLUNTARY – ADMISSION PROCESS IS INITIATED BY SOMEONE OTHER THAN THE CLIENT

24. SETTINGS • COMMUNITY HOSPITAL EMERGENCY ROOMS • RESIDENTIAL PROGRAMS • PARTIAL HOSPITALIZATION PROGRAMS • PSYCHIATRIC HOME CARE VISITS • COMMUNITY MENTAL HEALTH CENTERS

25. CULTURAL INFLUENCES ON MENTAL HEALTH AND MENTAL ILLNESS • A way of life • The learned pattern of behavior that shapes an individual’s thinking and that serves as the basis for one’s social, religious, and family structure. • A shared system of values that helps provide the framework for who we are

26. Ethnicity • The socialization patterns, customs, and cultural habits • Ethnic groups play important roles in preserving cultures • Values, traditions, expectations, and customs • Help people form relationships • Provide established guidelines for living • Function as focal points • Ethnicity helps establish one’s point of view

27. Religion • Relates to a defined, organized, and practiced system of worship • The values of religious groups range from those that allow for individual variation to those that require a commitment to place the religion before family, work, or friends

28. Stereotyping Mental Health Clients • Stereotype – an oversimplified mental picture of a cultural group • Extreme form of negative stereotyping is prejudice • Traditional stereotyping – assumes that all members of a culture behave in a certain manner or are a certain way

29. Six Components of Cultural Assessment • Communication • Space • Social organization • Time • Environmental control • Biological variations

30. Nursing Diagnoses • Altered Health Maintenance • Ineffective Management of Therapeutic Regimen • Impaired Thought Processes • Fear • Anxiety • Powerlessness • Self-esteem Disturbance • Impaired Coping • Social Isolation

31. NURSING PROCESS • Expected outcomes and goals are developed with cultural preferences in mind • Nursing care is formulated and then communicated by means of a written care plan • Implementation includes actual delivery of the planned nursing actions. • Client responses to care are assessed. • Many nursing actions are culturally significant to the client • Open mind is needed when observing client’s responses • Many reactions are culturally determined

32. DSM-IVTR MULTIAXIAL EVALUATION SYSTEM • Axis I- Clinical disorders and other conditions that may be a focus of clinical attention • Axis II- Personality disorders and mental retardation • Axis III- General medical conditions • Axis IV- Psychosocial and environmental problems • Axis V- The measurement of an individual’s psychological, social, and occupational functioning on the GAF Scale

33. Multidisciplinary Mental Health Team • Main purpose • Psychiatrists, social workers, psychologists, nurses and others • Develop comprehensive therapeutic plans • Cost-effective • Clients and significant others contribute to the plan of care • Remain actively involved • Interdisciplinary mental health care team

34. Health team members and their roles • Psychiatrist • Clinical Psychologist • Psychiatric Clinical Nurse Specialist • Psychiatric Nurse • Mental Health Technician • Psychiatric Social Worker • Occupational Therapist • Recreational Therapist • Music Therapist • Art Therapist • Dietician • Chaplain

35. LEGAL AND ETHICAL ISSUES • Ethics • Bioethics • Moral behavior • Values • Values clarification • Right • Absolute right • Legal right

36. ETHICAL CONSIDERATIONS • Theoretical perspectives • Utilitarianism • Kantianism • Christian ethics • Natural law theories • Ethical egoism

37. ETHICAL DELIMMAS • Ethical dilemmas occur when moral appeals can be made for taking either of two opposing courses of action. • Taking no action is considered an action taken.

38. ETHICAL PRINCIPLES • Autonomy • Beneficence • Nonmaleficence • Justice • Veracity

39. A MODEL FOR MAKING ETHICAL DECESIONS • Assessment • Problem identification • Plan • Implementation • Evaluation

40. Ethical Issues in Psychiatric/Mental Health Nursing • The right to refuse medication • The right to the least restrictive treatment alternative

41. LEGAL CONSIDERATIONS • Nurse Practice Act defines the legal parameters of professional and practical nursing • Types of Laws • Statutory law • Common law

42. Classifications Within Statutory and Common Law • Civil Law- protects the private and property rights of individuals and businesses • Torts • Contracts • Criminal law- provides protection from conduct deemed injurious to the public welfare

43. Legal Issues in Psychiatric/Mental Health Nursing • Confidentiality and right to privacy • Doctrine of privileged communication • Informed consent • Restraints and seclusion • False imprisonment • Commitment issues • Voluntary commitment • Involuntary commitment • Emergency commitment • The “mentally ill” person in need of treatment • Involuntary outpatient commitment • The gravely disabled client

44. Legal Issues in Psychiatric/Mental Health Nursing (cont.) • Malpractice and negligence • Types of lawsuits that occur in psychiatric nursing • Breach of confidentiality • Defamation of character • Libel • Slander • Invasion of privacy • Assault and battery • False imprisonment

45. LEAST RESTRICTIVE ALTERNATIVE • Providing mental health in the least restrictive environment. • Utilizing the least restrictive treatment. • Must look at alternatives such as day treatment, group home, home health etc. • Application of protective devices and restrains may constitute false imprisonment. • Must be used only to protect the client/others and as a last alternative.

46. RESTRAINTS • Physical and chemical • Documentation of other interventions and their lack of success r/t safety • Written order—if ER situation, verbal order may be obtained, then written within 4-8 hours. • Q15 min checks • Bathroom, exercise of limbs, offer liquids etc q2h • Released as soon as behavior under control

47. Nursing Actions to Avoid Liability • Responding to the patient • Educating the patient • Complying with the standard of care • Supervising care • Adhering to the nursing process • Documentation • Follow-up

48. THERAPUTIC RELATIONSHIPS • The nurse-client relationship • The therapeutic interpersonal relationship • Therapeutic use of self • Interpersonal communication techniques

49. The Therapeutic Nurse-Client Relationship • Therapeutic nurse-client relationships . • Therapeutic relationships are goal • Identify the client’s problem. • Promote discussion of desired changes. • Discuss aspects that cannot realistically be changed and ways to cope with them more adaptively. • Discuss alternative strategies for creating changes the client desires to make.

50. The Therapeutic Nurse-Client Relationship (cont) • Weigh benefits and consequences of each alternative. • Help client select an alternative. • Encourage client to implement the change. • Provide positive feedback for client’s attempts to create change. • Help client evaluate outcomes of the change and make modifications as required.