NCM 105 CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

NCM 105CARE OF CLIENTS WITH MALADAPTIVE PATTERNS OF BEHAVIOR

Prof. Melchor Felipe Q. SalvosaProf. Dodie A. Dichoso

Course descriptionThe course is designed to focus on health and illness across the lifespan of clients, population groups with acute and chronic psychosocial difficulties and psychiatric illnesses.

Course ObjectivesAt the end of the course, and given actual clients with maladaptive patterns of behavior, the student shall be able to:1. Utilize the nursing process in the care of individuals, families in community and hospital settings.Assess client/s with his/her/their condition through mental status examination, physical examination, interpretation of diagnostic procedures.Identify actual and potential nursing diagnosis.Plan appropriate nursing interventions with client/s and family for identified nursing diagnosis.Implement plan of care with client/s and family.Evaluate the progress of his/her/their clients condition and outcomes of care.

Course Objectives2. Apply knowledge and understanding of maladaptive patterns of behavior in providing safe and quality care to clients.3. Increase self-awareness and therapeutic use of self in the care of clients.4. Ensure a well-organized and accurate documentation system.5. Relate with client/s and their family and the health team appropriately.6. Observe bioethical concepts/ principles, core values and nursing standards in the care of clients.7. Promote personal and professional growth of self and others.

PrelimI. Overview of psychiatric nursingA. Evolution of mental health-psychiatric nursing practiceB. The mental health nurse 1. Role 2. Essential qualitiesC. Interdisciplinary teamD. The mental health illness continuum

II. Mental health-psychiatric nursing practiceA. Personality theories and determinants of psychopathology: Implications for mental health-psychiatric nursing practice 1. Psychoanalytic 2. Behavioral 3. Interpersonal 4. Cognitive 5. Humanistic 6. Psychobiologic 7. Cognitive 8. Psychosocial 9. Psychospiritual 10.Eclectic

B. General assessment considerations 1. Principles and techniques of Psychiatric nursing interview 2. Mental status examination 3. Diagnostic examinations specific to psychiatric patients

C. Building nurse-client relationship 1. Nurse-client interaction vs. nurse-client relationship 2. Therapeutic use of self 3. Therapeutic communication a. Characteristics b. Techniques 4. Goals in the one-to-one relationship 5. Phases in the development of nurse-client relationship

D. Documentation in psychiatric nursing practice 1. Problem-oriented recording a. SOAP 2. Narrative recording 3. Process recording

E. Therapeutic modalities, psychosocial skills and nursing strategies 1. Biophysical /somatic interventions a. Electroconvulsive and other somatic therapies b. Psychopharmacology

2. Supportive Psychotherapy a. Nurse-patient relationship therapy b. Group therapy c. Family therapy 3. Counseling 4. Mental health teaching/client education 5. Self-enhancement, growth/therapeutic groups 6. Assertiveness training 7. Stress management

8. Behavior modification 9. Cognitive restructuring 10. Milleu therapy 11. Play therapy 12. Psychosocial support interventions 13. Psychospiritual Interventions 14. Alternative Medicine /Therapies

F. Concept of Anxiety 1. Defining characteristics of Anxiety 2. Levels of Anxiety 3. Manifestations of Levels of Anxiety a. Physiologic b. Psychologic 4. Ego Defense Mechanisms a. Four levels of Defense

G. Crisis 1. Types of crisis 2. Phases of Crisis Development 3.Characteristics of Crisis 4. Crisis Intervention

MENTAL HEALTHIs a state of emotional, psychological, and social wellness evidenced by:Satisfying interpersonal relationshipsEffective behavior and copingPositive self-conceptEmotional stabilitySelf-awareness

COMPONENTS OF MENTAL HEALTH Autonomy and Independence-can work interdependently without losing autonomyMaximization of Ones Potential-oriented towards growth and self-actualizationTolerance of Lifes Uncertainties-can face the challenges of day-to-day living with hope & positive lookSelf-esteem-has realistic awareness of her abilities and limitationsMastery of the Environment-can deal with and influence the environmentReality Orientation-can distinguish the real world from a dream, fact from fantasyStress Management

Factors influencing a persons mental healthIndividual factors include a persons biologic makeup, sense of harmony in life, vitality, ability to find meaning in life, emotional resilience or hardiness, spirituality, and positive identityInterpersonal factors include effective communication, ability to help others, intimacy, and a balance of separateness and connection. Social/cultural factors include a sense of community, access to adequate resources, intolerance of violence, and support of diversity among people.

Mental IllnessHistorically viewed as possession by demons, punishment for religious or social transgressions, weakness of will or spirit, and violation of social normsToday seen as a medical problem, although some stigma from previous beliefs remains

Mental Disorder/Mental IllnessA clinically significant behavioral or psychological syndrome or pattern that occurs in an individual and that is associated with present distress, increased risk of suffering, death, disability and loss of freedom (Videbeck)Loss of ability to respond to environment in ways that are in accord with oneself and society

Factors contributing to mental illness Individual factors include biologic makeup, anxiety, worries and fears, a sense of disharmony in life, and a loss of meaning in ones lifeInterpersonal factors include ineffective communication, excessive dependency or withdrawal from relationships, and loss of emotional control. Social and cultural factors include lack of resources, violence, homelessness, poverty, and discrimination such as racism, classism, ageism, and sexism.

DIAGNOSTIC AND STATISTICALMANUAL OF MENTAL DISORDERS(DSM-IV-TR)

The DSM-IV-TR is a taxonomy published by APA and is used by all mental health professionals. It describes allmental disorders according tospecific diagnostic criteria.The DSM-IV-TR is based ona multiaxial classificationsystem:Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision

The DSM-IV-TR has three purposes: To provide a standardized nomenclature and language for all mental health professionals To present defining characteristics or symptoms that differentiate specific diagnoses To assist in identifying the underlying causes of disorders

A multi-axial classificationAxis I is for identifying all major psychiatric disorders except mental retardation and personality disorders.Examples include depression, schizophrenia, anxiety, and substance-related disorders.

Axis II is for reporting mental retardation and personality disorders as well as prominent maladaptive personality features and defense mechanisms.Axis III is for reporting current medical conditions that are potentially relevant to understanding or managing the persons mental disorder as well as medical conditions that might contribute to understanding the person.

Axis IV is for reporting psychosocial and environmental problems that may affect the diagnosis, treatment, and prognosis of mental disorders. Included are problems with primary support group, social environment, education, occupation, housing, economics, access to health care, and legal system.

Axis V presents a Global Assessment of Functioning (GAF), which rates the persons overall psychological functioning on a scale of 0 to 100. This represents the clinicians assessment of the persons current level of functioning; the clinician also may give a score for prior functioning (for instance, highest GAF in past year or GAF 6 months ago).

HISTORICAL PERSPECTIVES OFTHE TREATMENT OF MENTAL ILLNESS

Ancient TimesThose with mental disorders were viewed as being either divine or demonic depending on their behavior.Individuals seen as divine were worshipped and adored; those seen as demonic were ostracized, punished, and sometimes burned at the stake.

Aristotle (382322 BC) attemptedto relate mental disorders to physical disorders and developed his theory that the amounts of blood, water, and yellow and black bile in the body controlled the emotions.

These four substances, or humors, corresponded with happiness, calmness, anger, and sadness. Imbalances of the four humors were believed to cause mental disordersTreatmentaimed at restoring balance through bloodletting, starving, and purging. Such treatments persisted well into the 19th century

Early Christian times (11000 AD)Mentally ill were viewed as possessedPriests performed exorcisms to rid evil spirits. When that failed, they used more severe measures such as incarceration in dungeons, flogging, starving, and other brutal treatments.

exorcism

flogging

incarceration

starving

Renaissance (13001600),people with mental illness were distinguished from criminals in England.Harmless were allowed to wander the countryside or live in rural communities,More dangerous lunatics were thrown in prison, chained, and starved

St marys hospital

In 1547, the Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane.By 1775, visitors at the institution were charged a fee for the privilege of viewing and ridiculing the inmates, who were seen as animals, less than human

Period of Enlightenment andCreation of Mental Institutions1790s, a period of enlightenment concerning persons with mental illness began. Phillippe Pinel in France and William Tukes in England formulated the concept of asylum as a safe refuge or haven offering protection at institutions where people had been whipped, beaten, and starved just because they were mentally illBegan the moral treatment of the mentally ill.

In the United States, Dorothea Dix (18021887) began a crusade to reform the treatment of mental illnesspromoted adequate shelter, nutritious food, and warm clothing

Period of Scientific StudySigmund Freud (1856-1939) studied the mind, its disorders and their treatmentEmil Kraepelin (1856-1926) classify mental illness according to their symptomsEugene Blueler (1857-1939) coined the term Schizophrenia

1950 with the development of psychotropicdrugs

- Lithium (1949)- Chlorpromazine (Thorazine) (1950)MAOIsHaloperidol (Haldol)TCAsBenzodiazepinesFor the first time, drugs actually reduced agitation, psychotic thinking, and depression.

Deinstitutionalization began with the Community Mental Health Centers Act of 1963Community mental health centers served smaller geographic catchment (service) areas that provided less restrictive treatment located closer to the persons home, family, and friends.

Deinsitutionalization had three components: Release of individuals from state institutions, diversion from hospitalization, and development of alternative community services

1990's1. significant changes in the delivery of mental health treatment were made.2. manged care incorporated several new structures and services:- Casemanagement: involved the assignment of a case manger to coordinate services for individual clients and collaborate with multidisciplinary team.-critical pathways and care maps: served as clinical management tools to disintegrate the organization , sequence and timing of interventions provided by a treatment team for an identified client disorder.-Population -based community care: focused on primary preventive services and not just illness-based care;included identification of high-risk groups and education on lifestyle changes to prevent illness.

2000 to present1. the recovery and rehabilitation model, which was founded on the beliefs of individual client empowerment and control, focuses on the prevention or reduction of impairment in a client withs severe, persistent mental illness.

Psychiatric Nursing in the PhilippinesThe National Center for Mental Health (NCMH) was established thru Public Works Act 3258. It was first known as INSULAR PSYCHOPATHIC HOSPITAL, situated on a hilly piece of land in Barrio Mauway, Mandaluyong, Rizal and was formally opened on December 17, 1928. This hospital was later known as the NATIONAL MENTAL HOSPITAL, given on November 12, 1986, it was given its present name thru Memorandum Circular No. 48 of the Office of the President.

On January 30, 1987, NCMH was categorized as a Special Research Training Center and hospital under Department of Health. Today, NCMH has an authorized bed capacity of 4,200 and a daily average of 3,400 in-patients. It sprawls on a 46.7 hectare compound with a total of 35 Pavilions/Cottages and 52 Wards. The NCMH is a special training and research hospital mandated to render a comprehensive (preventive, promotive, curative and rehabilitative) range of quality mental health services nationwide.

Mental Illness in the 21st Century56 million Americans have a mental illness (DHHS, 2002)Hospital stays shorter, but more numerous: revolving doorIncreased aggression among mentally ill clientsAn increased number of people with mental illness are incarcerated

Mental Illness in the 21st Century (contd)Homeless population of persons with mental illness, including substance abuse, is growingMost health care dollars still spent on inpatient psychiatric care; community services not adequately fundedHealthy People 2010 mental health objectives strive to improve care of mentally ill persons

Mental Illness in the 21st Century (contd)Community-based care includes community support services, housing, case management, residential services outside the hospital Cost containment efforts include utilization review, HMOs, managed care, case managementCultural considerations: diversity increasing in U.S. in terms of ethnicity and changing family structures

PSYCHIATRIC NURSINGA specialized area of nursing practice employing theories of human behavior as its science and purposely use of self as its art.

PSYCHIATRIC NURSINGInterpersonal process whereby the nurse through the therapeutic use of self assist an individual family, group or community to promote mental health, to prevent mental illness and suffering, to participate in the treatment and rehabilitation of the mentally ill and if necessary to find meaning in these experiences

BASIC PRINCIPLES OF PSYCHIATRIC NURSINGAccept and respect the client regardless of his behavior.Limit or reject the inappropriate behavior but not the individualEncourage and support expression of feelings in a safe and non-judgmental environment. Increase verbalization, decreases anxiety.Behaviors are learned.All behavior has meaning.

Psychiatric Nursing PracticePsychiatric nursing practice emerged in 1873 when Linda Richards said, The mentally sick should be at least as well cared for as the physically sick1882 was first formal training of nurses in mental health First psychiatric textbook in 1920 This is a relatively new field in comparison with other areas

Psychiatric Nursing Practice (contd)Standards of Psychiatric-Mental Health Clinical Nursing Practice developed in 1973, revised in 1982, 1994, 2000Psychiatric Mental Health Nursing Phenomena of Concern: 12 areas of concern that mental health nurses focus on when caring for clients

AREAS OF PRACTICEBASIC-LEVEL FUNCTIONS CounselingInterventions and communication techniquesProblem solvingCrisis interventionStress managementBehavior modification Milieu therapyMaintain therapeutic environmentTeach skillsEncourage communication between clients and othersPromote growth through role-modeling

Self-care activitiesEncourage independenceIncrease self-esteemImprove function and health Psychobiologic interventionsAdminister medicationsTeachingObservations Health teaching Case management Health promotion and maintenanceADVANCED-LEVEL FUNCTIONS Psychotherapy Prescriptive authority for drugs (in many states) Consultation

PSYCHIATRIC MENTAL HEALTH NURSING PHENOMENA OF CONCERNActual or potential mental health problems pertaining to The maintenance of optimal health and well-being and the prevention of psychobiologic illness Self-care limitations or impaired functioning related to mental and emotional distress Deficits in the functioning of significant biologic, emotional, and cognitive symptoms Emotional stress or crisis components of illness, pain, and disability Self-concept changes, developmental issues, and life process changes Problems related to emotions such as anxiety, anger, sadness, loneliness, and grief

Physical symptoms that occur along with altered psychological functioning Alterations in thinking, perceiving, symbolizing, communicating, and decision-making Difficulties relating to others Behaviors and mental states that indicate the client is a danger to self or others or has a severe disability Interpersonal, systemic, sociocultural, spiritual, or environmental circumstances or events that affect the mental or emotional well-being of the individual, family, or community Symptom management, side effects/toxicities associated with psychopharmacologic intervention, and other aspects of the treatment regimen

Student ConcernsSaying the wrong thingWhat student will be doingFear of no one talking to studentBizarre or inappropriate behaviorPhysical safetySeeing someone known to the student

Self-Awareness IssuesEveryone has values, beliefs, ideas; nurses need to know what theirs are, not to change them, but to prevent unknown or undue influence on their nursing practiceHints to increase self-awareness: keep a journal, talk to trusted coworkers, examine points of view other than ones own

INTERDISCIPLINARY TEAM PRIMARY ROLESPsychiatrist: The psychiatrist is a physician certified in psychiatry by the American Board of Psychiatry and Neurology, which requires 3-year residency, 2-years of clinical practice, and completion of an examination. The primary function of the psychiatrist is diagnosis of, mental disorders and prescription of medical treatments.

Psychologist:The clinical psychologist has a doctorate (Ph.D.) in clinical psychology and is prepared to practice therapy, conduct research, and interpret psychological tests. Psychologists may also participate in the design of therapy programs for groups of individuals.

Psychiatric nurse: The registered nurse gains experience in working with clients with psychiatric disorders after graduation from an accredited program of nursing and completion of the licensure examination. The nurse has a solid foundation in health promotion, illness prevention, and rehabilitation in all areas, allowing him or her to view the client holistically

The nurse is also an essential team member in evaluating the effectiveness of medical treatment, particularly medications. Registered nurses who obtain a masters degree in mental health may be certified as clinical specialist or licensed as advanced practitioners, depending on individual state nurse practice acts. Advanced practice nurses are certified to prescribe drugs in many states.

Psychiatric social worker: Most psychiatric social workers are prepared at the masters level, and they are licensed in some states. Social workers may practice therapy and often have the primary responsibility for working with families, community support, and referral.Occupational therapist: Occupational therapist may have an associate degree (certified occupational therapy assistant) or a baccalaureate degree (certified occupational therapist). Occupational therapy focuses on the functional abilities of the client and ways to improve client functioning such as working with arts and crafts and focusing on psychomotor skills.

Recreation therapist: Many recreation therapists complete a baccalaureate degree, but in some instances persons with experience fulfill these roles. The recreation therapist helps the client to achieve a balance of work and play in his or her life and provides activities that promote constructive use of leisure or unstructured time.Vocational rehabilitation specialist: Vocational rehabilitation includes determining clients interests and abilities and matching them with vocational choices. Clients are also assisted in job-seeking and job-retention skills, as well as pursuit of further education if that is needed and desired. Vocational rehabilitation specialists can be prepared at the baccalaureate or masters level and may have different levels of autonomy and program supervision based on their education.