Download - Psych Theories
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Bridget Heyne, RNC, FNP,
MSN, Ed.D.
PSYCH THEORIES
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THEORY
Hypothesis, speculation, supposition
Attempt to explain human behavior
Explanation of behavior is based on the theoristassumptions, beliefs & world view
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Psychoanalysis
Psychoanalysisfocuses on discovering the causes of the
clients unconscious and repressed thoughts, feelings,
and conflicts believed to cause anxiety.
People do not like conflict so develop certain structures
in their mind or ways of responding to maintain
equilibrium& keep conflicts from causing too muchdiscomfort
Helping the client to gain insight into and resolve these
conflicts and anxieties 3
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Father of PsychoanalysisSigmund Freud
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FREUD-PSYCHOANALYTICTHEORY
Was a neurosurgeon who worked primarily with hysterical uppermiddle class women.
Most mental disorders were due to unresolved issues originatingin childhood (occurring during the first 5 years)
NO human behavior is an accident but is motivated by ansubconscious thought, feeling, need, wish or intent
Freud believed
that all psychologic and emotional events are understandable,
that childhood experiences caused adult neuroses, and thattherapy provided insight into the meaning of events.
Use of defense mechanismsto deal with an incompatible/unacceptable idea that causes internal conflict
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FREUD
Felt that there were different levels of psychological awareness
The mind as an iceberg
Conscious part is the tipof the iceberg. What we are aware
of- events and experiences we easily remember- phone #,
dates of special holidays. Conscious mind is thought to be
under the influence of the Ego
Preconsciousisjust belowthe surface of awareness. Are notreadily remembered but can be recalled relatively easily.
Unconsciouscontains unacceptable urges, repressed
memories. Greatly influences our feelings. Memories
retrieved by hypnosis, in dreams or incomprehensiblebehavior
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Personality Makeup
Id, Super ego & Ego which are entities of the mind, used toexplain observed behaviors resulting from conflicts r/t the needsof the individual, the restriction of society,& internal moral values
Idunconscious, primitive, pleasure principle, cannot tolerate
frustration, Impulsive, egocentric, cannot problem solve; We are allId at birth.
Superego (Perfection principle)concerned w/ moral & ethicalbehavior (all the should nots of life). Represents the ideal ratherthan the real. Legalistic, It seeks perfectionrather than pleasure..
Ego (Rational self or reality driven)- strives for balance, is themediator, mature adaptive behavior, reality tester, a problemsolver, develops defenses mechanism to help the individual dealwith stressful situations . Subject to anxiety if there is an imbalancebetween the Id & Super Ego. Ability to assess w/out anger or
aggression is an example of a healthy ego 7
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DEFENSE MECHANISMS
Used to protect individuals (Protective mechanism)from internal conflicts(feelings, memories) and
external stressorswhich causes the patient anxiety Used unconsciously .
Begins in childhood but become maladaptive ifused for too long(Gone with the wind)
Distorts, hides, denies reality, disruptiverelationships. Therefore, may project onto othershow they feel about themselves
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Table 5.1 Defense Mechanisms
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Table 5.1 Defense Mechanisms
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Defense Mechanisms
Regression- returning to an earlier level of adaptation. Adolescencesucking thumb & not speaking.
Not all defense mechanisms are bad. Some serve as health copingmechanisms used by mature adults
Altruism: emotional conflict & stress are dealt with by meeting theneeds of others. The person receives gratification by helping othersor from the response of others to being helped. 6 months afterloosing her husband, she spends 1 day a week doing grief counseling& is effective in helping others
Sublimation: substituting socially acceptable activity for strongunacceptable impulses. Strong hostile feeling are channeled byplaying a contact sport
Humor: Deals with stressors by emphasizing the amusing or ironic
aspectof the conflict (stand up comics) 10
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He defined anxiety as a feeling of tension, distress &
discomfort produced by a perceived or threatened loss of
control.
Felt that there was a repression or tucking away of things
that were unsafe to remember. This defense bandage
mechanism cannot be maintained for long & affects
personality & behavior Psychopathology results when a person has difficulty
transitioning from 1 stage to the next, when a person
remains at a particular stage but should have transitioned
upward or when there is regression to an earlier stage. 11
FREUD
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FREUD
Freud based his theory of childhood personalitydevelopment on the belief that sexual energy was the drivingforce of human behavior. There are 5 stages of psychosexualdevelopment: Based on sexual growth/development:
Oral stage (0-1 yr)smoking, biting, alcoholism. Sarcasticperson
Anal stage (1-3yr)-(anal retentiveness)-Obsessive/compulsive, Hoarding, stinginess, rigid thoughts;(anal explusiveness)- messiness, destructiveness
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FREUD
Phallic stage (3-6 yrs)-repression of attraction to the opposite
sex leading to same sex identification; lack of resolution results
in difficulties w/ sexual identity & difficulty w/ authority figure
Latency (6-12 yrs)conflict resolution w/ shift to other interest& friends. Difficulty identifying w/ others & developing social
skills. Sense of inadequacy
Puberty/ Genital (12 yrs & older)- reemerging sexuality.
Development of satisfying sexual & emotional relationships w/members of the opposite sex. Planning of life goal, emancipation
from parents. Problems; Non-satisfying intimate relationships,
lack of strong personal identity
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Harry Stack Sullivan
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SULLIVANSocial-Interpersonal Theory
Initially used the Freudian framework when working with
patients
Did not like dealing with the unseen & private mental process
w/in the individual
Sullivan interpersonal relationship theory is grounded in
observable behaviorthat resulted from patient interactions
Sullivan felt that the purpose of all behavior is to get needs met
through interpersonal interactions (develop security) & to
decrease or avoid anxiety (painful feeling or emotion arising
from insecurity)that may result from negative responses to an
interaction15
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Who I am & my sense of myself is built from childhood
experiences.
It results from reflected appraisals the person obtains
and learns to accept from contact with significant
others.
The self develops in the process of seeking
physical satisfaction of bodily needs and security. To feel secure, the self essentially requires feelings of
approval and prestige as protection against anxiety
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SULLIVAN
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SULLIVAN
Sullivan believed that the nurses role includeseducating clients and assisting them in developing
effective interpersonal relationships. Mutuality, respect for the client, unconditional
acceptance, and empathy are cornerstones ofSullivans theory.
The nurse must interact with the client A therapeutic environment (Milieu) is an accepting
atmosphere and provides opportunities for clientsto practice interpersonal skills
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ERIK ERIKSON
Stages of Development
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ERIK ERIKSON
Follower of Freud but felt that it was negative & restrictive
Eriksons developmental theory of personality attempted toaccount for biologic instincts as well as cultural andinterpersonal tasksthat must be accomplished to move forwarddevelopmentally.
Each stage of growth involves maintaining a balance betweendisorder & stability to adjust & move forward to the nextlevel/stage.
Successful resolution affects success in next stage
Failure to resolve stage may lead to psychological symptoms atlater time
His model spans the full life cycle & felt that personality
continues through old age (Unlike Freud) 19
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ERIK ERIKSON
This theory can help identify age appropriate or arresteddevelopmental interpersonal skillsas clients with mental
illness usually exhibit some degree of developmental delayor incomplete resolution of developmental task thatparallel their chronological age
Helps the nurse know what types of interventions are mostlikely to be effective based on the developmental level ofthe client through assessment of their developmentalfunctioning
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Eriksons Stages
Trust vs. Mistrust(0-1 1/2yrs)The major task is todevelop a basic trust in mothering figure & be able togeneralize it to others. Suspicious, problem relating to
others Autonomy vs.. shame & doubt (1 -3) -Gain self control &
independence within the environment w/o loss of selfesteem. Shame- something is wrong with me(I am
wrong, ). Severe self doubt Initiative vs. guilt(3-6)- The goal is to develop a sense of
purpose & the ability to initiate & direct ones own activity(Exploration & daring). Guilt(I have done something wrong).
Sense of inadequacy &/ or guilt 21
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Erickson's Stages
Industry vs Inferiority(6-12)- Development & mastery ofsocial & cognitive skills.Task is to achieve a sense of selfconfidence (Social skills) by learning, competing & receiving
recognition from significant others, peers & acquaintances.Difficulty learning & working, sense of inferiority
Identity vs. role diffusion/confusion(12-20) secure senseof self & realization of competencevs feeling that will
never be good enough. Confusion about who one is Intimacy(able to nurture self & others, to commit) vs.
isolation(20-35). Goal is to form lasting relationships or acommitment to another person or cause. Emotional
isolation, egocentricity 22
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Erickson's Stages
Generativity vs. stagnation(35-65) Creative, concern for
others & future generations vs self indulgence, self
absorption, inability to grow, despair over aging Ego integrity vs. despair(65+ to death)Review of ones life
& derive meaning from events in ones life, sense of
fulfillment, Positive sense of self worth vs loss of hope,
helpless, denial & despair over the prospect of death
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Abraham MaslowMaslows Hierarchy of Needs
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MASLOW
Focused on human Needs Fulfillment
Proposed an order of basic human needs.Physiological needs must be met before higher-level
needssuch as self-esteem and self actualization Sequencing nursing actions based on client priority
needs
Emphasized nursing prioritization of action in caring
for the patientto take collect anything other theessential info when a client is struggling w/ drugw/drawl is inappropriate
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MaslowsBasic Needs
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MASLOW
Physiological Needsbiological need for food, shelter etc
Safety and security-is the one of the most basic need-avoiding harm, physical safety & security, order, limits,
Love and belonging-companionship, giving & receivinglove, relationships
Esteem and self-esteem-respect from others, success,achievement
Self-actualization-takes years to achieve- fulfillment ofunique potential, becoming everything that one is capableof becoming. An example of a highly evolved mature,balance individual
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Burrhus Frederic SkinnerClassical Conditioning
19041990
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B. F. SKINNER
Classical Conditioning
Behaviorismfocuses on behaviors and behavior changes,rather than explaining how the mind works
Behaviorist- Human behavior is learned
Behavior has consequences (reward or punishment)
Rewarded behavior tends to recur
Positive reinforcement increases the frequency of behavior-
Operant conditioning29
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B. F. SKINNER
Removal of negative reinforces increases the frequency of behavior
Negative consequences decreases the likelihood of a behavior
Continuous reinforcement is the fastest way to increase behavior;random intermittent reinforcement increases behavior more slowlybut with longer-lasting effect
Therefore learned behavior responses can be modified
Treatment modalities based on behaviorism include behaviormodification, token economy (get a token for a desired behavior),and systematic desensitization, Aversion therapy (punishment- )
Modeling behavior
Milieu-safe supportive environment with emphasis on group & social
interaction. Rules through peer pressure30
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Jean PiagetsCognitive Theory
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Jean PiagetsCognitive Theory
Cognitive therapy
focuses on immediate thought processing.
How a person perceives or interprets an experience
determines how you feel & behave . Therefore must helpcorrect distorted perceptions and dysfunctional beliefs.
Cognitive behavioral theoryfocuses on the present ratherthan the past. Symptoms associated with neuroses andpsychoses are identified as clusters of learned behaviors
that persist because they are rewarding to the individual.
Must learn to think more adaptively and realistically. Mustsubstitute rational beliefs for irrational beliefs & eliminate
self defeating behavior32
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Biological Theory
Focuses on neurological, chemical, biological, c &
genetic issues to understand how the brain & body
interact to create emotion, memories & perceptualexperiences
Views abnormal behavior as a disease process or
defect (usually in Limbic system of the brain) Targets site of the defect/ illness using surgery or
drugs33
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Nursing Theorists
Nursing theories assist nurses to:
Organize assessment data,
Identify problems,
Plan interventions,
Generate goals and nursing actions,
And determine and evaluate outcomes.
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Hildergard PeplauThe Mother of Psychiatric Nursing
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Hildergard Peplau
Emphasized the interpersonal nature of nursing andthe need for nurses to use psychodynamic conceptsand counseling techniques
Nurse/client relationship
The nurse-client relationship is structured toprovide a model for adaptive interpersonal
relationships that can be generalized to others Interpersonal experience is a learning experience
for the nurses and can benefit both the nurse &client
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MADELEINE LEININGER
Cultural Care, Diversity and Universality
Historically interventions centered on illness rather
on prevention & health promotion
Must have understanding of clients culture &
associating stress that may lead to mental illness
Important of respect in Hispanic culture. Asian-avoids conflict, watch for non- verbal's
Mental illness occurs within cultural framework
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DOROTHEA OREM
A Behavioral Nursing theory which focuses on selfcare deficit & includes both physical and psychosocialhuman needs
Nursing care is needed when person can no longerprovide self-care (inability to maintain life, health,and well-being)
Needs (i.e. seriousness of mental illness) indicateappropriate nursing system
Concretebecause of an underlying disorder, thepatient neglects self eg eating, rest, personal
hygiene, rest, safety38
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Culture
Still not well understood
Describes a particular societys entire way of living,
including beliefs, feelings & knowledge. These
guides the members conduct & are passed down
from one generation to the next
Learned through socialization
Shared by all group members
Ever-changing and dynamic
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Culture & Mental Illness
Culture determines:
What behavior is normal/what is abnormal(Behavior thatis normal at a party is unacceptable at a business meeting).
Often mental illness is seen as the degree to which aperson fails to fulfill the expectation of the culture
What beliefs are acceptable/what are not(What may beperfectly acceptable in one culture may be criminal in
another). Concepts of mental health/mental illness. Stigma varies
Acceptability of various treatment modalities, (exorcism,coining).
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Cultural Competence
Practice standards to ensure that clients of all cultures
receive information about treatment in
understandable ways considering education,acculturation, and language.
An essential step toward developing culturalcompetence is to examine ones own perceptions,
prejudices, and stereotypes regarding the particular
cultural group of interest.41
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The Culturally CompetentMENTAL HEALTH NURSE
Nurse must understand own culture
Will be aware of similarities and differences
between clients culture and nurses culture Will plan culturally sensitive care
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The Culturally CompetentMENTAL HEALTH NURSE
Will have knowledge of central beliefs and behaviors ofclients culture
Will assess level of integration and identification with thedominant culture
Cultural Assessment
Adopt open and objective attitude toward others
Recognize that variation within cultural groups exists
Adapts care to the clients needs & preferences
(continues)43
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Stages in Acquiring CulturalCompetence
Unconscious Incompetence
Not being awareof lacking information aboutother cultures
Conscious incompetence- Being aware of lacking information about
other cultures but do not care
Conscious Competence
Actively learningabout other cultures andverifying information
Unconscious Competence
Automaticallyproviding culturally competent care44
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Spirituality
Includes core beliefs about people, the divine, and relationsbetween them. May derive comfort & inner strength fromspiritual beliefs(decreases anxiety)
Influenced by culture, life experiences
Helps connect people to each other, the community, theworld
Along with religion and faith, may be experienced andexpressed in a variety of ways
Client may need support from priest, Rabbi especially incases of spiritual distress.
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ETHICS
Is the rightness or wrongness of an action, the
goodness or badness of ones motive, & the results
(good or bad) of action taken
Important in psychiatric nursing- dilemma of the
right or obligation to the client vs obligation to the
community Understanding basic principles can help in decision-
making
What one should do46
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ETHICS
Ethical Dilemmas- Is a situation that requires an
individual to make a choice between 2 equally
unfavorable alternatives
The dilemma generally creates overwhelming
emotional responses
Often the reasons supporting each sides of the
argument is logical & appropriate
Examples: right to refuse medication, the right to
the least restrictive treatment alternative47
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News Flash
Not guilty by reason of insanity is a phrase that
evokes passion in many people. Jeffery Dahmer, the
cannibalist murderer, did not say that he did not do
it. He said he was not guilty because he did not
know what he was doing.
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Insanity Defense
Insanity: the person could not control his or her actionsor understand the difference between right and wrongat the time of the crime(MNaghtenrule)
13 states have provisions for a guilty but insaneverdict that holds the person responsible for the crimewhile ensuring that he or she receives treatment.
If the are unable to understand the charges against
themthen they cannot be tried for the crime until theydo. Must be able to participate in their own defense.
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Legal Issues inMENTAL HEALTH NURSING
Law is involved in psychiatric nursing-individuals
who do not understand the nature or implications
of unlawful actions because of insanity cannot be
held legally accountable for their actions
Must balance rights of client and society: Tarasoff
vs the Regents of the University of California. MH
Professionals have a duty to warn of threat of harm
to others50
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Legal Issues inMENTAL HEALTH NURSING
Laws set out rules and procedures: Rogers vs. Okin
(Boston), patients right to refuse medication. Had
significant implications for nurses who are temptedto force patients to take their medication for
their own good.
Laws differ from state to state
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L l I i th
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Legal Issues in theCOMMUNITY
Informed consent-for medication & treatment
Sexual involvement with clients
Breaching confidentiality Self-destructive and violent behavior
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CLIENTS RIGHTS
Right to privacy- a consent form must be signed torelease confidential information about a patient
Right to keep personal items
Right to enter into legal contracts
Right of habeas corpus ( court proceeding to seekjudicial discharge)
Right to informed consent
Right to refuse treatment
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TORT
A civil wrongor wrongful actagainst a person that
violates his or her rights & results in injury, loss or
damage
Unintentional Torts
Negligence:harm caused by failure to do what is
reasonable and prudent (Suicidal patient near an
open window)
Malpractice: (Professional negligence) is
negligence or incompetence on the part of a
professional that causes harm to the client54
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Intentional Torts
Assault: An act that results in a persons
genuine fear & apprehension thatthe personwill be touched w/out their consent
Battery:harmful or unwanted actual contact
False imprisonment: unjustifiable detention.Holding a competent person against his or her will by verbal or
physical means. Actual force is not a requirement. The individual
needs only to be placed in fear of imprisonment by someone who
has the ability to carry out the threat
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Intentional Torts
Slander: the sharing of information orallythat could be
detrimental to the clients reputation
Libel:sharing of information in writingthat could be
detrimental to the clients reputation
Deformation of character: when information is shared that
could be detrimental to a clients reputation, the nurse
may be at risk for defamation of character. Documentedinformation should reflect objective findings, not the
nurses perception of the client.
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Least Restrictive
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Least RestrictiveEnvironment
Treatment must be provided in the least restrictive
environment appropriate to meet the clients needs
Physical restraint or seclusion in a locked room can
be used only when the person is imminently
aggressive or threatening to harm himself
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Least Restrictive
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Least RestrictiveEnvironment
Restraint and seclusion, if used, must be in place for
the shortest time necessary & after de-escalation
has failed
Many regulations govern the monitoring of clients
in seclusion or restraint for their safety
Maintain contact & assure the
client that seclusion is a way
to maintain safety
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Confidentiality
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ConfidentialityHIPAA (1996)
Need the clients consent to disclose information to
anyone except those necessary for the
implementation of the clients treatment plan
Both civil (fines) and criminal (prison sentences)
penalties exist for violation of patient privacy
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Duty to Warn Third
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Duty to Warn ThirdParties
Duty to warn a third party is an exception to clientconfidentiality (Tarasoff ruling)
Clinicians must warn identifiable third parties of threatsmade by a client
Nurse must record this in their nurses notes & inform thephysician, & other members of the health care team(treatment team) so the appropriate steps taken
Is the client dangerous to others
Is the danger the result of a serious mental illness Is the danger serious
Are the means to carry out the threat available
Is the danger targeted at a particular person/victim
Is the victim accessible60
VOLUNTARY
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VOLUNTARYADMISSION
Client makes direct application to the institution
for service
May sign out of facility at any time unless the
HCP following mental status examination that the
client may be harmful to..
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Involuntary Admission
If client is a
A danger to self- emergency admission
To others Mentally Ill
Unable to provide for basis needs- gravely disabled
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EMERGENCY
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EMERGENCYADMISSION
A legal hold resulting temporary suspension of the
civil rights of a person
Detained for short time (valid for 72 hours)/5150
Will assess need for longer treatment
Usually carried out by police in most jurisdictions
Client must be deemed a danger to self (DTS), adanger to others ( DTO) or Gravely Disabled
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EMERGENCY
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EMERGENCYADMISSION
Gravely Disabled means that the individual is
Not able to provide or make practical use of food,
clothing & shelter
May be released earlier if a licensed practitioner
decides that they no longer meet the above
criteria
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Civil Commitments
5250allows for a hold extension of the 5150 up to14 days
This extension occurs only if the person remains aDTS, DTO or GD
A hearing must occur w/in 3 business days with an
unbiased hearing officer Even if psychotic or severely depressed but not a
DTS, DTO or GD, then you cannot hold this person
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Civil Commitments
5260 Danger to self only ( Imminently suicidal). Can
be kept for additional 14 days
5270 Gravely Disabled only. Can have up to 30 day
hold
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Civil Commitments
Writ of Habeas Corpus ( a demand to appear before
a judge)
A hearing to determine if a patients legal rights
are being suspended w/o cause
Staff assist the patient to fill out forms & must
come before a judge as soon as it is possible
Judge decides if patient is to be released or under
go further treatment
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Civil Commitments
Sterling Hearing
Made regarding the legality of a legal hold
Both the patient & the hospital facts arepresented
No decision is made on length of stay or any
treatment issues
Decision only involves whether patient will stay
or be released immediately
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Civil Commitments
Reese Hearing
When it is determined that a patient requires treatmenteg medication but the patient refuses
Must show that the patients impairment outweighs thepotential risk of the medication.Medication will in allprobability provide the help the patient needs
That the patient is not able to evaluate the benefits of
the treatment in question Patient must show logical reason for refusal of the
medication
Judge decides if the medication/treatment can be given
against the patients will69
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Civil Commitments
T- Con ( Temporary Conservatorship)
Legal hold filled by the public Guardian Officer in
Superior court
With patient unable to make informed decisions
about their care
Valid for 30 daysto allow time for treatment
Another court date set prior to end of T-Con todetermine if further treatment is necessary & T-Con
should be extended70
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Civil Commitments
Many clients view these restrictive interventions as
forms of abuse, while mental health care providers
see them as helping people who cant take care ofthemselves.
It is assumed that a person without a mental
disorder would not choose suicide. Thus, mentalhealth caregivers seek to prevent suicide on the
basis that this is what the client would choose if the
client were mentally capable of choosing. 71
Prevention of
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Prevention ofLiability
Nurses can minimize the risk of law suits through
safe competent nursing care & descriptive accurate
nursing care Nurses can minimize the risk of
lawsuits through safe, competent nursing care anddescriptive, accurate documentation
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THE END
Question #1
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Question #1Please choose an answer
Determine the type of communication occurring in the following
example:
Nurse: Good morning, Mrs. Jones. How did you sleep last night?
Patient: I had a lousy night. The person in the next room kept yelling in
his sleep.
Nurse: I know what you mean, sometimes my husband does that too.
Im luckier than you were because I can shake him & get the
shouting to stop. I guess you wont feel comfortable doing that to
another person you dont really know.
Patient: No, Besides that, who wants to walk around here at night? Still,
I think I want to meet him. He looked pretty when I saw the nurse
taking him around the unit after he was admitted74
Question #1
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Question #1cont
This interaction should be assessed as:
a) Therapeutic
b) Collegial
c) Sociald) Intrapersonal
A- Does not promote client growth & is not client focused
B- Is used for professional collaboration
C- Is superficial, Of benefit to both individuals. No expectationof help exist
D- Takes place w/in an individual75
Question #2
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Question #2Please choose an answer
The nurse has begun to treat the client as a mutual
friend, focusing on topics of social interest and
seeking support from the client. The result that
can be anticipated is most likely to be:
a. blurred boundaries and role confusion.
b. establishment and maintenance of trust.
c. client experiencing freedom to grow.
d. collaboration to determine client needs.
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Question #3
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Question #3Please choose an answer
A psychiatric technician mentions that little of what takesplace on the behavioral health unit seems to be theorybased. The nurse can enlighten the technician by citing thefact that many of Sullivans theoretic constructs are used in
A. the ongoing use of restraint and seclusion as behaviormanagement tools.
B. the structure of the therapeutic milieu of mostbehavioral health units.
C. assessment tools based on age-appropriate versusarrested behaviors.
D. the method nurses use to determine the best sequencefor nursing actions.
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Question #3
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Question #3answer
The structure of the therapeutic environment has as foci anaccepting atmosphere and provision of opportunities forpracticing interpersonal skills. Both constructs are directlyattributable to Sullivans theory of interpersonal
relationships. Option:
A: Sullivans interpersonal theory did not specificallyconsider use of restraint or seclusion. Option
C:Assessment based on developmental level is more theresult of Eriksons theories. Option
D: Sequencing nursing actions based on client priorityneeds is related to Maslows hierarchy of needs.