Foundations of Psychiatric / Mental Health Nursing A Clinical Approach – 6 th edition

Mental Health and Mental Illness Foundations of Psychiatric / Mental Health Nursing A Clinical Approach – 6 th edition

Mental Health Able to recognize own potential Cope with normal stress Work productively Make contribution to community

Traits of Mental Health Ability to Think rationally Communicate appropriately Learn Grow emotionally Be resilient Have a healthy self-esteem

Mental Illness Considered clinically significant when marked by Patient’s distress Disability or Risk of disability or Loss of freedom Is culturally defined

Diathesis-Stress Model Diathesis – biological predisposition Stress – environmental stress or trauma Most accepted explanation for mental illness Combination of genetic vulnerability and negative environmental stressors

Social Influences on Mental Health Care Mental health movement National Alliance on Mental Illness (NAMI) Decade of the brain New Freedom Commission on Mental Health Mental Health Parity Act

Epidemiology of Mental Disorders Study distribution of mental disorders Identify high-risk groups Identify high-risk factors Lead to etiology of mental disorder Use information to Improve clinical practice Plan public health policies

In the DSM-IV-TR Mental disorders are considered a manifestation of a dysfunction of the individual Behavioral Psychological or Biological The Diagnostic and Statistical Manual of Mental Disorders, 4th edition, text revision (DSM-IV-TR) is used to classify diagnostic categories for psychiatric disorders.

The DSM-IV-TR Multiaxial System Axis I: Mental disorder that is the focus of treatment Axis II: Personality disorders and mental retardation Axis III: General medical disorder relevant to the mental disorder in axis I Axis IV: Psychosocial and environmental problems Axis V: Global Assessment of Functioning (GAF)

ICD-10 International Classification of Disease Clinical descriptions of mental and behavior disorders Divided into 10 disease classifications

NANDA-I The North American Nursing Diagnosis Association International (NANDA-I) describes a nursing diagnosis as a clinical judgment about individual, family, or community responses to actual or potential health problems and life processes.

Levels of Psychiatric Nursing Practice Generalist Level Advanced Practice Each has clearly defined roles

Caring for Psychiatric Mental Health Clients Feelings, Concerns, Questions—What Are They? Who are the clients with mental illness?

People with Mental Illness

Healthy People 2020 Reduce suicide rate Reduce the rate of suicide attempts by adolescents Increase services for homeless adults with serious mental illness (SMI) Reduce relapse with eating disorders in adolescents Increase mental health screening in primary care services Increase mental health services in children

Healthy People continued Jail diversion programs for SMI Cultural competency Plan that address specialized mental health services for the elderly persons. Increase services for person with co-occurring substance abuse and SMI Increase consumer involvement

Effective Mental Health Services Partnership PMH Team Client Family

Relevant Theories and Therapies for Nursing Practice

Freud's Psychoanalytic Theory Levels of awareness Conscious Preconscious Unconscious

Freud's Psychoanalytic Theory Continued Levels of awareness in relation to id, ego, and superego Id: Present at birth. Serves to satisfy needs and immediate gratification Ego: Begins to develop at 4 – 6 months. Maintain contact with reality, rational part of personality. Superego: begins to develop at about 3 – 6 years. Serves as conscience (sense of right or wrong)

Freud's Psychoanalytic Theory Continued Defense mechanisms and anxiety Operate on unconscious level Deny, falsify, or distort reality to make it less threatening Experiences during the early stages of life determine an individual's lifetime adjustment patterns and personality traits.

Freud's Psychoanalytic Theory Continued Oral—0 to 1 year: weaning Anal—1 to 3 years: toilet training Phallic—3 to 6 years: oedipal conflict Latency—6 to 12 years: hides sexuality from disapproving adults Genital—12 to 20 years: genital sexuality

Freudian Theory and Nursing Formation of personality Conscious and unconscious influences Importance of individual talk sessions Attentive listening Transference Countertransference

Erikson's Ego Theory Eight stages of development Personality continues to develop through old age Failures at one stage can be rectified at another stage

Erikson's Theory and Nursing Developmental model is important part of nursing assessment Helps determine what types of interventions are most likely to be effective

Sullivan's Interpersonal Theory Purpose of all behavior is to get needs met through interpersonal interactions and to decrease or avoid anxiety Security operations

Sullivan's Theory and Nursing Foundation for Hildegard Peplau's theory Participant observer Mutuality Respect for the patient Unconditional acceptance Empathy

Nursing Theories

Nursing Theories Impacting Psychiatric Nursing Marjory Gordon – Functional Health Patterns (1987) Hildegard Peplau – Interpersonal Relationships (1952) Dorothea Orem – Self-Care Deficit (1959) Dorothy Johnson – Behavioral System (1968) Sister Callista Roy – Adaptation Model (1976)

Hildegard Peplau The art of nursing Provide care, compassion, and advocacy Enhance comfort and well-being The science of nursing Application of knowledge to Understand a broad range of human problems and psychosocial phenomena Intervene in relieving patients' suffering and promote growth

Peplau and the Therapeutic Relationship Peplau influenced by Sullivan's work Interpersonal Relations in Nursing (1952) Major paradigm shift in nursing Levels of anxiety

Hildegard Peplau, PhD, RN, FAAN

Marjory Gordon,PhD, RN, FAAN

Behavioral Theories Pavlov's classical conditioning theory Watson's behaviorism theory Skinner's operant conditioning theory Implications for nursing Altering targeted behaviors Behavior management

Behavioral Therapy Modeling Operant conditioning Systematic desensitization Aversion therapy Biofeedback

Cognitive Theories Rational-Emotive Behavior Therapy (Ellis) Aims to eradicate irrational beliefs Recognize thoughts that are not accurate Cognitive-Behavioral Therapy (Beck) Test distorted beliefs and change way of thinking; reduce symptoms

Maslow’s Hierarchy of Needs Human beings are active participants in life, striving for self-actualization Basic needs D-motives/deficiency needs Self-esteem and self-actualization B-motives/being needs

Maslow’s Theory and Nursing Emphasis on human potential and the client's strengths Prioritizing nursing actions in the nurse-client relationship

Maslow: Self-Actualization and Hierarchy of Needs

Biological Theories Focus on Neurological Chemical Biological Genetic How do the body and brain interact to create Emotions Memories Perceptual experiences

Biological Theories and Nursing Consider other influences that play a role in the development and treatment of mental disorders Social, environmental, cultural, economic Focus on the qualities of a therapeutic relationship Apply newest findings of biological model in nursing practice

Additional Therapy Milieu Therapy Use of total environment People, setting, structure, and emotional climate all important to healing

Serious Mental Illness (SMI)

Affects 5.4% of U.S. population Presents difficulties in multiple areas Associated issues of poverty, stigma, unemployment, and inadequate housing Chronic or recurrent Patients at risk for multiple physical, emotional, and social problems Varying degrees of disability

Older Adults with SMI Before deinstitutionalization, psychiatric hospitals were long-term residences Patients became dependent on services and structure and were unable to function independently

Young Adults with SMI Limited experience with formal treatment Contributes to denial that a problem exists and inability to realize they have an illness Increases risk for problems, such as legal difficulties, substance abuse, and unemployment

Rehabilitation and Recovery Rehabilitation – focuses on Managing patients’ deficits Helping them learn to live with their illness Recovery – focuses on Achieving goals of patient’s choosing Leading increasingly productive and meaningful lives

Issues Confronting Those with SMI Establishing a meaningful life Comorbid conditions Physical disorders Depression and suicide Substance abuse

Issues Confronting Those with SMI Continued Social problems Stigma Isolation and loneliness Victimization

Issues Confronting Those with SMI Continued Psychiatric mental health clients are everyday, ordinary people. Removing the stigma of Mental Illness Definition of Stigma: a mark of disgrace or infamy; a stain or reproach, as on one’s reputation Best defined as ignorance, prejudice and discrimination

A ward in Bethlehem Hospital about A patient is being chained in the foreground, and in the background are two Sunday visitors on an entertainment outing. Source: Philosophical Library.

Issues Confronting Those with SMI Continued Economic challenges Unemployment and poverty Housing instability Caregiver burden Treatment issues Nonadherence Anosognosia Medication side effects Treatment inadequacy Residual symptoms Relapse, chronicity, and loss

Resources for Persons with SMI Comprehensive community treatment Community services and programs Psychiatric or medical-somatic services Case management Medication monitoring Assertive community treatment (ACT) Day programs Crisis intervention services

Resources for Persons with SMI Continued Community services and programs Emergency psychiatric services Group and individual psychotherapy Housing services Partial hospitalization programs (PHPs) Guardianship Community outreach programs Substance abuse treatment

Evidence-Based Treatment Approaches Assertive community treatment (ACT) Cognitive-behavioral therapy (CBT) Cognitive-enhancement therapy (CET) Family support and partnership Social skills training Supportive psychotherapy Vocational rehabilitation and related services

Other Potentially Beneficial Services or Treatment Approaches Advance directives Consumer-run programs Wellness and recovery action plans (WRAP) Technology Exercise

Nursing Care of Patients with SMI Assessment strategies Nursing diagnoses (Table 30-2) Intervention strategies (Box 30-2)

Current Issues Involuntary treatment Criminal offenses and incarceration Transinstitutionalization

The Nursing Process and Standards of Care for Psychiatric Mental Health Nursing

Standards of Care Standard 1: Assessment Age considerations Assessment of children Assessment of adolescents Assessment of older adults Language barriers

Psychiatric Mental Health Nursing Assessment Gathering data Review of systems Laboratory data Mental status examination Psychosocial assessment

Psychiatric Mental Health Nursing Assessment Continued Gathering data, continued Spiritual/religious assessment Cultural and social assessment Validating the assessment Using rating scales

Standard 2: Diagnosis Three components Problem (unmet need) Etiology (probable cause) Supporting data (signs and symptoms)

Standard 3: Outcomes Identification Outcome criteria – outcomes that reflect the maximal level of patient health that can realistically be achieved through nursing interventions

Standard 4: Planning Principles to consider when planning care Safe Compatible and appropriate Realistic and individualized Evidence-based

Standard 5: Implementation Basic level interventions Coordination of care Health teaching and health promotion Milieu therapy Pharmacological, biological, and integrative therapies

Standard 5: Implementation Continued Advanced practice interventions Prescriptive authority and treatment Psychotherapy Consultation

Standard 6: Evaluation Systematic Ongoing Criteria-based