Documenti di Didattica
Documenti di Professioni
Documenti di Cultura
Mental Health
Nursing
UCSF
School of Nursing
Morality
Reform
Medicalization
Potions, Lotions and
Notions
Bodily humors
Evil spirits
Deification
Lobotomy 1936
ECT 1937
Cold wraps
Emil Kraeplin
DSM I 1952
Hildegard Peplau
By the 1920s, psychiatric nursing became an
official and separate curriculum at most
colleges and universities, and by 1950, the
National League for Nursing required nursing
schools to include psychiatric nursing in
their clinical practice for national
accreditation. The role of the psychiatric
nurse expanded when the Community
Mental Health Act of 1963 encouraged
deinstitutionalization and psychiatric drugs
that allowed patients to live on their own
became more common.
Early “Enlightenment”
Phillipe Pinel: late 18th century
Benjamin Rush: Moral Treatment
Dorothea Dix and Linda Richards
Clifford Beers: A Mind That Found Itself
Mental Hygiene Movement
Moral Treatment
Control the patient without punishment
Constructing order
Compassionate Discipline
McLean’s Hospital
1882
1st school to prepare nurse for the care of the
mentally ill – 2 year program
Few psychological skills were taught, care was
primarily custodial (e.g. medication,
nutrition, hygiene, & ward activities)
Principles of medical/surgical nursing were
adapted to the psychiatric setting
Linda Richards
American reformer Dorothea Dix noted
that mentally ill patients were treated
like animals in 19th-century America,
and she opened 32 state asylums to
care for them. English reformer and
nursing pioneer Florence Nightingale
fought for quality care for the
mentally ill. She collaborated with her
American colleague, Linda Richards
and inspired Richards to open Boston
City College in 1882.
Johns Hopkins 1913
1st SON to develop a course for psychiatric
nursing that was incorporated into the
nursing curriculum
Muddling through…
Sigmund and his disciples: Construction of
the Self
Peplau: Interpersonal Relations Model
Mental Health Act 1946
National Institute of Mental Health 1949
Chlorpromazine
Mental Health Study Act 1955 & 1963
Deinstitutionalization
The battle
continues….
Anti-psychiatry
Community Mental Health
Patients Rights
Community Support Programs 1977
Managed Care
New Freedom Commission 2002: stigma, consumer
driven, disparities, research, service and
technology
Mental Health Parity Act 1996 and 2008
Proposition 63
Enlightenment for
real?
Psychoanalysis and psychological disrobing
The end…..
5th Amendment: double jeopardy, self incrimination and due
process
14th Amendment: equal protection
California Constitution
Lanterman Petris Short (LPS) Act: 1967-1972
LPS
To provide prompt evaluation and treatment.
To guarantee public safety.
To safeguard individualized treatment, supervision
and placement.
To encourage full use of existing agencies,
professional personnel and public funds.
To protect mentally and developmentally disabled
persons from criminal acts.
LPS and Involuntary
Detention
Restrict persons authorized to initiate involuntary
detention.
Specify criteria under which persons with mental
illness may be committed.
Establish mandatory time frames for each escalating
period of involuntary detention.
Provide opportunity to challenge each stage of
commitment by providing access to administrative
and judicial review.
W & I 5325.1
Patients’ Rights
A right to treatment services which promote the potential of the person to function independently. Treatment
should be provided in ways that are least restrictive of the personal liberty of the individual.
A right to be free from harm, including unnecessary or excessive physical restraint, isolation, medication,
abuse, or neglect. Medication shall not be used as punishment or for the convenience of staff, as a
substitute for program, or in quantities that interfere with the treatment program.
Denial of Rights
Seclusion or restraint must be closely
monitored
Denial of any right must be documented and
substantiated by staff
Riese Decision
The court stated that to have some irrational fears
Monitor facilities for compliance with patients’ rights laws and regulations and are a
resource for service providers for information, technical assistance and training.
Advocates focus on the resolution of the complaint. Advocates work for the
expressed interest of the individual and support them using self-advocacy to
accomplish their goal.
Advocates outreach to vulnerable clients, visiting them at facilities and clinics and
where they reside.
WIC 5520
5150 criteria
Danger to Self
Danger to Others
Grave Disability
Contextual considerations
Danger to Self
This criteria may be either a deliberate intention to injure oneself
(i.e.overdose) or disregard of personal safety to the point
where injury is imminent (i.e. wandering about in heavy
traffic).
The danger must be present, immediate, substantial, physical
and demonstrable.
Words or actions showing intent to commit suicide or bodily
harm.
Words or actions indicating grossdisregard for personal safety.
Words or actions indicating a specific plan for suicide.
Means are readily available to carry out a plan
Danger to Others
Should be based on words or actions that indicate the person in
question either intends to cause harm to a particular
individual or intends to engage in dangerous acts with gross
disregard for the safety of others.
Threats against particular individuals
Attempts to harm certain individuals
Means available to carry out threats or to repeat attempts
(firearms other weapons)
Expressed intention or attempts to engage in dangerous activity
Grave Disability
A condition in which a person, as aresultof amental disorder, is unable to provide his or her basic personal
needs for food, clothing and shelter.
Although consideration of past events may be necessary, evaluation must be based on individual’s current
condition.
If friends or family are willing to provide for the person’s basic needs, then the criteria for grave disability is
not met.
irrational beliefs about the food (e.g., it is poisoned or tainted in some way)
Does NOT meet
criteria for a 5150
Willful or volitional behavior
Criminal behavior
Conscious acting out secondary to disappointment, anger,
hate, passion, fanaticism or prejudice
Simply having a psychiatric diagnoses
Implications of
Involuntary Detention
With no other illness you do you use police power to detain people to
evaluate and then involuntarily treat them.
Being picked up by police in handcuffs
Individuals may feel they have been kidnapped
Clients report experiencing severe loss of self-esteem and trust in the
provider
Clients have complained of being in crisis and approaching their outpatient
clinic for support to get help, only to be 5150’d when they would have
accepted help voluntarily.
Clients feel powerless being unable to address their responsibilities: pets,
bills, parking, counseling appointment, court appearances,
employment, etc..
Beyond 5150
5250: 14 day hold
Temporary Conservatorship: 30 days
Permanent Conservatorship: 1 year
For any of the above, the individual may:
Risk of Violence
Male
Youth
History of violence
Not in treatment
Abuse as a child
HIPAA
Disclosure requires specific release from the client
Disturbance in Mood
Evolving Case Study
Jane is a 32 yo Asian female who is admitted to
the locked psychiatric unit. Jane told her
outpatient therapist that she had been
suicidal for the past three weeks
Scenario I
What are the possible reasons why Jane might
be placed on a locked unit?
Are there any parameters within the State of
California for placing a client on a locked
unit? What are they?
Are there protections for such individuals?
What are they?
As a nurse who is responsible for admitting Jane
to the unit what might be some of your
initial activity and interaction with Jane?
Scenario II
Her husband and a sister accompany Jane.
They report that Jane has been acting
different over the past month. They note
that she has been sleeping less, speaking in
a very voluble and garrulous manner, pacing
a lot, and indicating that she has a special
relationship with President Obama. Her
husband is particularly concerned as he
thinks she has been “sleeping” around.
Questions
Given that a mental status exam is a routine
part of a psychiatric admission, what parts
of the mental status exam are indicated
above?
What other questions will you begin to
formulate for Jane or her husband and
sister? How would handle asking questions
of her husband and sister?
What are the possible diagnoses for Jane and
what are the criteria for those diagnoses?
Scneario III
Given some more information, we learn that
Jane was on some unknown medication
“years ago for her mood.” She has been in
therapy due to interpersonal difficulties at
home and at work. We find out that she has
tangential thinking, racing thoughts,
decreased need for sleep, delusions of
grandeur, impulsive spending, excessive
drinking and sexual activity with strangers.
Questions
What is the possible diagnosis at this point?
What are the criteria for this diagnosis?
What are the possible medications for this
disorder?
What are the side effects of these medications?
What are the nursing indications for
administration?
Under what circumstances might we administer
this medication on an involuntary basis?
Scenario IV
Jane has now been admitted to the unit, she is
on suicide precautions, ordered to receive
olanzapine 5 mg. po BID; Ativan 1.0 mg prn
q 4 hours and Benedryl prn for side effects.
She has been pacing around the unit a
significant amount, receiving about two
hours of uninterrupted sleep, entering other
patients’ rooms, claiming to be influential
with all level of local and national politicians
and declining regular meals but hording food
in her room.
Task
Using Orem’s model propose a plan of
intervention for each domain
Scenario V
Jane has been in the hospital for four days now
and is sleeping about 6 hours, no longer
going into other patients’ rooms, no longer
claiming to have special influence in high
places and is now denying suicide ideation.
Questions
How do we evaluate suicidal risk?
Dysthymia
Bipolar I
Bipolar II
Major Depression
4. Sleep change
Specifiers
MDE Illness Course
Duration is variable
Untreated, typically lasts for 6 months or longer
In the majority of cases there is complete
remission of sxs and functioning returns to
premorbid levels
In about 20-30% of cases, some depressive sxs
persist for months to years and may be
associated with significant disability and
distress
About 5-10% of individuals may still meet all
criteria for MDD for 2 or more years
Dysthymic Disorder
1. Poor appetite
2. Insomnia or hypersomnia
3. Low energy or fatigue
4. Low self-esteem
5. Poor concentration or difficulty making
decisions
6. Feelings of hopelessness
Big Picture for BAD
w Prevalence; Type I = 1%; Type II = 4%
w Worldwide disability: one of the top illnesses
w Onset: 20s; possible in children and
adolescence
w Demographics: I. 1:1, II. 2:1, F:M; + family
hx;
w Association with suicide: 15 -20%
w Treatment efficacy: following an average of 7-9
episodes
Bipolar I
w Classic manic-depressive form of the
illness
w Most severe type of bipolar disorder.
w Characterized by at least one manic episode
or mixed episode.
w Major Depression not required for diagnosis
but most do experience a MDE
w Typical course of Bipolar I Disorder
involves recurring cycles between mania
and depression.
w
Bipolar II
Hypomania and depression
Substance abuse
Physical illness
Medication
Injury
Schizophrenia or schizoaffective illness
Grief
Impact of Affective
Illness on Functioning
Affective
Cognitive
Physiological
Behavioral
Affective
Sad
Hopeless
Teary
Anhedonia
Irritable
Expansive
Euphoric
Flattening
Cognitive
Concentration/ Distractibility
Morbidity
Grandiosity
Paucity
Negative: worthless, guilt, suicide ideas
Tangential
Flight of ideas
Decreased judgment
Physiological
Psychomotor slowing or activation
Sleep disturbance
Appetite disturbance
Amenorrhea
Behavioral
Suicide attempt or gesture
Withdrawn
Intrusive
Hyper-social or hypersexual
Age
Race
Genetics
Education
Religion
Mental state
Physical Health
‘97: 111
‘98: 90
‘99: 101
‘00: 111
San Francisco
Locations
Private residence
GGB
Hanging
Firearms
Behavior
Speech
Mood/Affect
Thought Process
Thought Content
Suicide ideation
Plan
Means
Loss
Future
Electroconvulsive
Treatment
Controversial
Indications
Administered w/ general anesthesia + muscle
relaxant
Electrodes placed unilateral or bilateral
Sz is induced for up to a minute
6 -12 treatments up to 3x /week
Remission and Maintenance
Memory loss
Nursing Interventions
Support
Empathy
Validation
Physiological
Adequate intake
Hygiene
Sleep
Breathing
Relaxation
Cognitive
Delusions: support and reality testing
Offering hope
Addressing negative thinking
Identification
Challenging
Reframing
Detaching
Stopping, substitution distraction
Guided imagery
Behavior
Limit setting
Contracting
Monitoring
Isolation or seclusion
Group interaction
Regulation of contacts
Mobilization
Personality Disorders
personality disorder
Intensive
Maladaptive and inflexible
Troublesome
Diagnostic Criteria
Behavioral pattern that deviates from the norm
in perception, response, control of impulse
and interpersonal function
Enduring: not a response to a specific situation
Impairs functioning
Three Clusters
A. Paranoid, Schizoid, Schizotypal
Asocial
Eccentricities
Schizotypal
Peculiar beliefs
Blunted affect
Asocial
Avoidant
Fearful
Apprehensive
Risk averse
Dependent
Submission
Insensitive to others
Dramatic
Self absorbed
Narcissistic
Inflation of self import
Mood dysregulation
Impulsive
Interpersonal drama
Symptom Focus
Mistrust
Anger or belligerence
Impulsivity
Inappropriate behavior or insensitivity
Manipulation
Poor coping
Oversensitivity
Mal-adaptation
Interventions
Personal reaction Explanation and Interpretation
Use of self Relaxation
esteem
Dialectical Behavior
Therapy
Mindfulness
Interpersonal effectiveness
Emotional regulation
Distress tolerance
Substance Abuse and
Pharmacology
Who uses
Context
Neuroanatomy
Neuron
Neurotransmitters
Side effect
Med classes
Dual Diagnosis
Context
Serendipity and medication discovery
Evolutionary: expanding role of pharmacy and increased use
Controversial: influence of pharmaceuticals, family and
consumer concerns
Effectiveness: percentage of responders
Adverse effects
Placebo: drug, set and setting
Costs
Patients rights/ rights to refuse
Who prescribes?
Formulary
Role of FDA
Substance Use
Who is using what?
Results from the 2006 National Survey on Drug Use and Health:
Usage
2006 CY Lifetime
Cigarettes: 35% 71%
Alcohol: 66% 83%
Illicit drugs 14% 45%*
*Illicit Drugs include marijuana/hashish, cocaine (including crack), heroin,
inhalants, stimulants, PCP, ecstasy, or prescription-type psychotherapeutics
used nonmedically.
Nicotine Dependence
Based on SAMHSA's National Survey on Drug Use
In 2007, an estimated 22.3 million persons
(9.0 percent of the population aged 12 or
older) were classified with substance
dependence or abuse in the past year based
on criteria specified in DSM-IV.
Of these, 3.2 million were classified with
dependence on or abuse of both alcohol and
illicit drugs, 3.7 million were dependent on
or abused illicit drugs but not alcohol, and
15.5 million were dependent on or abused
alcohol but not illicit drugs.
Co-occurence
According to SAMHSA
Antidepressants
Mood stablizers
Antipsychotics
Antidepressants
MAOIs
TCAs
SSRIs
SNRIs
Atypical
Monamine Oxidase
Inhibitors
Mechanism of action is theinhibition of enzymes that metabolize
neuroepinephrine and serotonin. Also inhibits dopamine
The major concern with the MAOIs is the dietary restriction which if
not followed cd cause a hypertensive crisis. MAO interacts with
tyramine, an amino acid derivative. Some of these foods are
chocolate, cheeses, red wine, banana skins, caffeine, beer, certain
pickled foods
Most common: nardil ( phenelzine); Parnate ( tranylcypromine);
Marplan (Isocarboxazid).
These meds tend not to be sedative and have no ACH s/e
Doses are usually 15 mg to 90 mg.
Tricyclic / Tetracyclic
These drugs have a long half life hence can usually be Rx in
daily dosing. They are notable for their anticholinergic SE,
orthostasis, and sedation. Dosing usually begins fairly low
and will be titrated as the patient appears to tolerate the SE.
therapeutic effects will occur in 2 – 6 weeks. Known to be
effective in 60% of consumers. Although clients may need to
start and d/c a number of trials before they experience
benefit.
SE: can include anxiety, sedation, short term memory loss,
sexual dysfunction, weight gain.
SSRIs
Prozac, Paxil, Luvox, Lexapro, Zoloft came on the
inhibitors (cymbalta/duloxetine,
effexor/venalfaxine)
Atypical
Work on differing combinations of neurotransmitter
1940s an Austrian MD inadvertently discovered Li use in mania by studying the uric acid content of
persons with mania
effective in a good percentage of persons with BAD but it also highly toxic
needs to be taken in multiple daily doses due to it relatively short half life.
Tim release preparations that provide opportunity for TID or BID dosing.
Toxicity requires regular monitor of kidney and thyroid function at the start of treatment and in
relatively frequent intervals following.
Important for the pt to not take medication for 12 hours before lab assay
Not given in the acute phase as it takes a few weeks to stablize a pt. Anti-psychotic medications are
almost always given during the acute phase and becoming first line for many pts
Anticonvulsants
An increasing a number of medications that were
Haldol
Haldol which is probably the medication that was
most used in emergency situations
Potency is measured the degree of dopamine
receptor blockade. Occupancy at the D2
receptors is cited as the mechanism of action
for decreasing the positive symptoms of
schizophrenia
The more potent the drug, the greater the
potential for EPS but less anticholinergic
S/E.
Long acting agents that are injected in fat
tissue, usually the gluteus or deltoid
Newer Generation
Newer meds act on a wider variety of
neurotransmitters and quickly bind and release
from the D2 receptors. Effectiveness is also
attributed to 5HT2 (serotonin) blockade hence
some impact on negative ss.
Improved s/e profile, less EPS
May impact perceptual, thought, motor, affective
and interpersonal disturbances
Newer Generation
Clozaril: effective and promised to impact
negative sx. SE: Agranulacytosis
Risperidone
Olanzapine: metabolic syndrome
Quetiapine: smaller contribution to metabolic
syndrome
Others: ziprasidone, aripiprazole
EPS and Parkinson
Treatment
Amantadine
Bromocriptine
Cogentin
Artane
Benedryl
General
Considerations
Gender, size, race and ethnicity, personality, medical illness, psychiatric dx
What is recovery: optimism and strengths based
Trial and error
Education
Provider relationship: partnering with the client; being open and direct; de-
mystifying the process; being aware of the power dynamics; to be
available and to be used as a resource
Use of family and supports
Inventory of all that the individual is placing in their body
Effectiveness
Side effect
Drug interactions
Client choice and negotiation
Non-compliance
Monitoring, evaluation and laboratory assay
Barriers to
Compliance
Highest with anti-psychotics
Effectiveness
Depot
Substance Abuse
Criteria
Defined as a maladaptive pattern of substance use leading to
hazardous
Seizures
-Within 48 hours of last drink
Alcoholic Hallucinosis
- 12- 24 hr. onset after last drink
- Usually visual
Delirium Tremens
-
5% of patients
-
DT Symptoms
Hallucinations
Disorientation
Tachycardia
Hypertension
Agitation
Diaphoresis
Intervention
Very frequent monitoring
vomiting
Sweats
Observation:
0 No sweat visible
7 Drenching sweats
Anxiety
Ask “Do you feel nervous, anxious or
shakey?” Observation:
0 No anxiety, at ease
1 Mildly anxious
4 Moderately anxious, or guarded, so
anxiety is inferred
7 Equivalent to acute panic states as
seen in severe delirium or
Agitation
Observation:
0 Normal activity
0 None
5 Severe hallucinations
7 Continuous hallucinations
Auditory
Ask “Are you more aware of sounds around you? Are they harsh? Do they
frighten you? Are you hearing anything that is disturbing you? Are you
hearing things you know are not there?” Observation:
0 Not present
5 Severe hallucinations
7 Continuous hallucinations
Visual
Ask “Does the light appear to be too bright? Is its colour different? Does it
hurt your eyes? Are you seeing anything that is disturbing you? Are you
seeing things you know are not there?” Observation:
0 Not present
2 Mild sensitivity
3 Moderate sensitivity
5 Severe hallucinations
7 Continuous hallucinations
Headache
Ask “Does your head feel different? Does it feel like there is a band
0 Not present
1 Very mild
2 Mild
3 Moderate
4 Moderately severe
5 Severe
6 Very severe
7 Extremely severe
Orientation and
Sensorium
Ask “What day is this? Where are you? Who
am I?”
calender days
calender days
apart. Observation:
0 No tremor
to fingertip
4 Moderate, with patient’s arms
extended
7 Severe, even with arms not
extended
Co-morbid
Pharmacological
Guidelines
Treat both disorders: pharmacological and
psychosocial
Differential diagnosis
Patient motivation and benefit for use
Consider using pharmacological antagonists
Treat during withdrawal, of course considering
interactions
Minimize use of meds that have a potential for abuse
and dependence
Continue to treat the psychiatric disorder while the
client continues to use while maintaining safety
and evaluation of effectiveness
Use of laboratory assay to determine interactions and
presence of other drugs
Guidelines (continued)