Psychiatric-Mental Health Nursing Overview

Lecture 1 Objectives

Describe mental health and mental illness Discuss psychiatric-mental health nursing from a historical perspective Discuss basic assumptions of several theoretical approaches to mental illness Differentiate the use of the nursing as applied to psychiatric-mental health nursing Identify the roles of brain anatomy and neurophysiology in brain dysfunction Describe effective communication techniques Differentiate between normal age related changes and mental disorders in older populations Explain the importance of understanding cultural diversity in mental illness Identify key elements of legal/ethical issues in mental health nursing

June A. Tierney, PhD(c),APRN-BC

This material is based upon work supported by the Ohio Learning Network. Any opinions, findings and conclusions or recommendations expressed in this material are those of the author and do not necessarily reflect the views of the Ohio Learning Network.

Adapted: Hodson D. & Smith, G.B (2003) Overview of P-MH Nursing

Definitions

Overview of Psychiatric-Mental Health Nursing

Mental Health Mental Illness

Ageism Competency Countertransference Culture Diagnostic and Statistical Manual of Mental Disorders (DSM IV-R) Discrimination Ethnocentrism Ethnicity Mental Health

Mental Illness Negative Bias Neurotransmitters Prejudice Stereotypes Subculture Therapeutic Communication Therapeutic Relationship Transference Values

DSM IV-R Multiaxial System

Axis Axis Axis Axis Axis I II III IV V

Mental Health and Mental Illness Continuum

Physical level Personal level Interpersonal level Societal level

Goal vs. Process Mental Disorders

Historical Perspective

Historical Developments
1800s
Shift in treatment, level of dignity, science holds some promise Asylums, study of the mind Linda Richards & McLean Psychiatric Asylum Least restrictive environment and patient rights evolve Medications are discovered Hildegarde Peplaus framework, definition of psychiatric nursing practice Deinstitutionalization, community treatment Community Mental Health Centers Act (1963) Population-based community care with focus on prevention and mental health promotion Behavioral Managed Care, multidisciplinary planning, Decade of the Brain (1990) focuses on disease process

Mental Illness
Community Mental Health Act (1963)

1950-1960

Current focus: management

Managed care Least restrictive care Americans with Disabilities Act (1990) Consumer movement Decade of the Brain

1960-1980

Psychiatric-mental health nursing

Linda Richards Harriet Baily Hildegarde Peplau

1980-Present

Psychiatric-Mental Health Nursing Practice

Theoretical Contributions Significant to PsychiatricMental Health Nursing

Generalist
Population and Education level Interventions Practice Settings

Intrapersonal Theory
Sigmund Freud

Anxiety Defense Mechanisms

Compensation Denial Displacement Identification Intellectualization Introjection Minimization Projection Rationalization Reaction Formation Regression Repression Sublimation Substitution Undoing

Specialist

Education level Psychiatric Nurse Practitioners Clinical Nurse Specialists

Standards of Care and Practice

ANA (1994) Standards of Care Standards of Professional Performance

Theoretical Contributions Significant to Psychiatric-Mental Health Nursing cont.

Theoretical Contributions Significant to Psychiatric-Mental Health Nursing cont.

Intrapersonal Theory cont.

Erik Erikson

Social-interpersonal Theory
Harry Stack Sullivan Abraham Maslow
Physiological Needs Safety Love and belonging Esteem and recognition Self-actualization

Stages of Development Sensory Muscular Locomotor Latency Adolescence Young Adulthood Maturity

Hildegarde Peplau Feminist Theory Social-Interpersonal Models

Behavioral Theory
B. F. Skinner Education and program design

Theoretical Contributions Significant to Psychiatric-Mental Health Nursing cont.

Theoretical Contributions Significant to Psychiatric-Mental Health Nursing cont.

Cognitive Theory
Jean Piaget

Biogenic Theory
Incidence via genetic and environmental factors Genes, neuroanatomy, neurophysiology, biological rhythms

Sensorimotor Preoperational

Concrete Operational Formal Operation

Aaron Beck

Cerebrum

Cognitive schemas Cognitive distortions (self, present, future)

Frontal lobe Parietal lobe Occipital lobe Temporal lobe

Albert Ellis

Diencephalon
Thalamus Hypothalamus Limbic System

Cognitive restructuring

Theoretical Contributions Significant to Psychiatric-Mental Health Nursing cont.

The Nursing Process

Provides boundaries for psychiatricmental health nursing & scientific method for delivery of nursing care Steps

Biogenic Theory cont.

Neurotransmitters
Serotonin (5-HT) Norepinephrine (NE) Dopamine (DA) Acetylcholine (ACH) Gamma-aminobutyric acid (GABA)

Biological rhythms

Temperature, energy, sleep, arousal, motor activity, appetite, hormones, and mood Biological clock Adrenal rhythm, temperature patterns, sleep patterns

Assessment Diagnosis Outcome identification Planning Implementation Evaluation

The Nursing Process cont.

Therapeutic Relationship

Assessment
Observation: behavior, affect, cognition, interpersonal relationships, physiology Psychosocial: client and family history Neuropsychiatric: appearance, activity, speech, emotional state, cognition, perception

Definition
Physical, psychosocial, spiritual, power components Focus on client needs

Diagnosis

Applicable to individual, family, groups, communities

Outcome identification
Criteria for measuring achievement

Three Phases
Introduction

Planning

Safety needs are priority over physiological needs Client may not be able to participate at first

Contract, confidentiality, assessment, preliminary plan of care Implementation

Transference countertransference

Working

Implementation Evaluation
Formative Summative Documentation

Termination

Review progress, plan for future

Therapeutic Communication

Therapeutic Communication cont. Effective Communication Techniques

Definition Foundation of Interpersonal Relationships

Communication includes: Nonverbal communication Listening Effective helpers Techniques to facilitate communication Ineffective communication

Broad Opening Giving Recognition Minimal Encouragement Offering Self Accepting Making Observations Validating Perceptions Exploring

Clarifying Placing the event in time or sequence Suggesting collaboration Restatement Reflection Summarizing

Therapeutic Communication cont. Ineffective Communication Techniques

Stereotypical comments Parroting Changing the topic Disagreeing Challenging Requesting an explanation

Older Adults

Etiology Assessment
Differentiating between dementia, delirium, and depression Hearing loss Functional assessment

False reassurance Belittling expressed feelings Probing Advising Imposing values Double or Multiple questions

Nursing Diagnoses
Chronic, Impaired, Risk for

Interventions
Prone to side effects and toxic effects
Dosage and progression Restraints ECT Reminiscence

Cultural Considerations

Legal and Ethical Issues

Autonomy Voluntary

Culture

Subculture, ethnicity, ethnocentrism Culture and mental health

Values Attitudes and perceptions

Bias and negative bias Generalizations and stereotypes Prejudice and discrimination

Caring for a culturally diverse population

and liberty admission Commitment & involuntary admission Competency Informed consent Confidentiality Nursing ethics

NCLEX Test-taking Tips

Application Question

Application and Analysis questions

Application: why Analysis: show relationships, cause and effect

Best Answer
First read the background statement, then read the stem, noting key words Attempt to answer the question before reading the four options If physiological, priority follows ABC rule If psychological, priority follows SEA rule If RN response type: dont solve, reflect, dont change the subject or discount client feelings, do develop understanding Feelings are not good or bad, they just are. Behaviors can be good or bad, and lead to consequences

A client who is hospitalized for panic disorder is experiencing increased anxiety. The client exhibits selective inattention and tells the nurse, Im anxious now. The nurse determines that the degree of the clients anxiety is:
Mild Moderate* Severe Panic

*The nurse must know the facts related to the levels of anxiety. The nurse must be able to differentiate the correct level of anxiety the client is experiencing in order to implement appropriate nursing action.

Analysis Question

A hospitalized client with depression asked the nurse, Do you think I should go home this weekend? The nurse uses the technique of reflection when the nurse responds:
Should you go home for the weekend?* Home means? It sounds as if you havent decided whether or not to go home this weekend. Do you think you really have to go home this weekend? *The nurse must know the relationship of refection in order to distinguish the cause and effect between it and the other communication techniques used in the situation.