introduction to psychiatric nursing module 2: concepts rnsg 2213
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Introduction to Psychiatric NursingModule 2: Concepts
RNSG 2213
History Concepts
How were mentally ill treated prior to1790’s? Banishment Confinement
What were attitudes toward them? Possessed by the devil Lacked basic human qualities
St. Mary of Bethlehem Hospital, London (“Bedlam”) Opened to lunatics 1403
Visitors pay for “entertainment”
History Concepts
Period of Enlightenment begins in 1790’s Concept of “ Asylum” (sanctuary):
If we treat patients humanely and
respectfully, they will improve. Mental illness worsens with stress
First mental hospitals (“asylums”) in US in 1820’s
History Concepts
Who was Dorthea Dix? A nurse who was one of the first major
reformers in the United States. Helped develop the concept of an asylum Direct role in opening 32 state hospitals
Dorthea Dix Asylum in North Carolina
Austin, Texas State Insane Asylum 1851
Era of Psychotropic Drugs
Medications first available in 1950s, i.e. chlorpromazine (Thorazine) for Schizophrenia, Lithium for Mania
Hope for previously “incurable” mental illnesses and enhanced quality of life.
Community Mental Health Movement Response to the overcrowding and bureaucracy of public
mental hospitals. Chronically mentally ill “warehoused” and often
abused, neglected 1963 Community Mental Health Act
Concept: Patients can be treated better, cheaper in community
Massive deinstitutionalization: All State Hospitals in some states closed
Results: Increased acuity and strain on emergency services, increased number of homeless mentally ill
ETHICAL ASPECTS: SOCIAL VALUES(Consider what effect each of these values has on mental health care) Individual Freedom Money Paternalism vs Libertarianism
Paternalism believes that an authority knows what is best for you
Libertarianism believes that the individual knows what is best for them
No other area of nursing is so affected by social values as psychiatric nursing
A Nurse Needs to Know About:
How to adapt legal principles to mental health settings: safeguarding nursing practice from charges of
negligence, false imprisonment, assault, or battery DUTY TO WARN
Mental health professionals must warn others of a client’s threat of suicide or of harm to self or others
Rights of Psychiatric/Mental Health Patients
Right to refuse treatment Right to informed consent ( and the right to
know about rights) Right to confidentiality Right to receive visitors and telephone
calls Right to be treated with respect Right to be treated in the least restrictive
environment
Client Rights
Concept of Least Restrictive Environment: Should guide nursing decisions Seclusion is used when the person is a danger to
others Restraint is used when the person is a danger to
self Never used to get a patient to comply
Rights of Mentally Ill Patients Basic Needs:
Warmth: clothing a blanket Food Access to the outdoors
Contact with family, legal representative Do NOT have right to all possessions
(When can access to possessions be restricted?)
Legal Aspects: Commitments
(As Applied under Texas Law) Mental illness as defined by the Texas Mental
Health Code “Mental illness is a disease or condition
which either: Substantially impairs the person’s thought,
perception of reality, emotional process and/or Grossly impairs behavior as manifested by a
recent event of disturbed behavior (“Gravely disabled”)
Commitments
Voluntary Commitment A person 16 years of age or over signs
themselves in for admission. Person is advised of their rights under the code.
4 Hour Rule: If a patient changes their mind about being in the hospital, psychiatrist has 4 hours to file for a commitment.
Signs a consent for treatment.
Commitments, cont’d
Most commitments are voluntary where the individual or the therapist request admission and the patient meets criteria for admission
The patient must sign consents for all psychotropic medications. Refusal to sign these consents means the medications can NOT be administered
Involuntary Commitments
Emergency Mental Illness Commitment Allows Mental Health Deputies (Crisis Intervention Team) to pick up a person who presents an “IMMINENT DANGER TO SELF OR OTHERS” and is “Gravely Disabled”
and bring them into custody for 24 HOURS. MD can begin commitment procedures (file)
at that time.
Involuntary Commitments, cont’dOrder of Protective Custody (OPC) Commitment must be accompanied by a
medical certificate, which states that the physician has examined the patient within 24 hours. Filed at the County Clerk’s Office.
Probable Cause Hearing within 72 hrs. Pt. can be committed for 14 days.
Involuntary Commitments, cont’dTemporary Commitment Papers must be filed with the Court Hearing before a judge with physician and patient
present. Must prove “Danger to self or others” or meets the
deterioration standard Can be committed UP TO 90 DAYS. May be discharged any time staff believes pt. is
ready. May change to Outpatient Commitment
Involuntary Commitments, cont’dExtended Mental Health Commitment
Very strong evidence needed Commitment is up to 1 year.
Last but not least . . . .
All involuntary commitments can include court-ordered medications
All commitments discussed previously can apply to Chemical Dependency
TREATMENT SETTINGS AND THE CONTINUUM OF CARE Where do we see the mentally ill being
treated? How do individuals enter the mental health
system? Why is discharge planning so important?
PSYCHOTHERAPEUTIC MANAGEMENT TOOLS ARE:
SELF DRUGS ENVIRONMENT
Therapeutic Use of SELF (Nurse-Client Relationship)
DRUGS: Psychopharmacology ENVIRONMENT: Therapeutic Milieu
NURSE ON THE MENTAL HEALTH TEAM Mental Health Team:
Psychiatrist Nursing staff: includes licensed nurse, tech Psychiatric Social Worker Psychologist Therapeutic Recreation and Expressive Arts
personnel Client and Family Other: Substance abuse counselor, employment
specialist, dietician, etc.
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