Mental Health Mental Health Nursing IINursing II

NURS 2310NURS 2310

Unit 1Unit 1

Basic Concepts of Basic Concepts of Mental Health and Mental Health and

Mental IllnessMental Illness

Objective 1Objective 1

Exploring the historical overview of care of the

mentally ill client

In the Beginning No known treatment for the mentally

ill before 1840– Mental illness perceived as incurable– Only “reasonable” intervention was

removing mentally ill persons from the community

The Birth of Community Mental Health Provided for reimbursement of mental

health services through Medicare and Medicaid

Resulted in the “deinstitutionalization” of the mentally ill

Deinstitutionalization of the Mentally Ill The deinstitutionalization movement

occurred throughout the late 1950’s and early 1960’s– 500,000 people lived in state mental

hospitals in 1955– Right to freedom at issue

Communities unable to sustain care for mentally ill– Insufficient planning– Budget cuts reduced mandated services– Mentally ill became homeless– Outcome is “revolving door” syndrome

The Problems That Remain The mentally ill comprise a great

majority of the homeless population Many person with chronic mental illness

end up in jails and emergency rooms Not enough community services/facilities

to provide adequate care for mental illness

Medicaid, Medicare, and other 3rd-party payers do not reimburse mental health services at the same rate as medical services

Continuing stigma of mental illness

Objective 2Objective 2

Reviewing concepts related to mental health and mental

illness

Mental health The successful adaptation to stressors from

the internal or external environment, evidenced by thoughts, feelings, and behaviors that are age-appropriate and congruent with local and cultural norms.

Mental illnessMaladaptive responses to stressors from the internal or external environment, evidenced by thoughts, feelings, and behaviors that are incongruent with local and cultural norms, and interfere with the individual’s social, occupational, and/or physical functioning.

Self-esteemOne’s opinion of oneself; a confidence and satisfaction in oneself.

Self-awarenessAn awareness of one’s own personality or individuality.

SanitySoundness or health of mind; one’s ability to bear legal responsibility for one’s actions.

ResilienceAbility to recover from or adjust easily to misfortune or change.

Well-beingThe state of being happy, healthy, or prosperous.

EmpowermentTo promote the self-actualization or influence of.

AssertivenessThe expression of opinions, needs, and feelings without negating the opinions, needs, and feelings of others.

Objective 3Objective 3

Identifying members of the mental health team and their

roles

Psychiatrist Medical doctor with special training in mental

illness and behavioral/emotional problems Diagnoses conditions and prescribes medical

treatment

Clinical psychologist Provides individual and group therapy Performs psychiatric testing

Therapist Provides individual therapy Conducts group therapy sessions

Social worker Community resource education Discharge planning

Recreation therapist Incorporates leisure activities in group settings

to demonstrate healthy coping mechanisms

Nurse Administers medications Conducts group education sessions Provides patient support and directs patient

care

Psychiatric technician Assists nursing staff Provides support to client

Objective 4Objective 4

Reviewing the ANA Standards of Psychiatric

and Mental Health Nursing Practice

The American Nurses’ Association (ANA) has identified five standards of psychiatric and mental health nursing practice:Standard I – AssessmentStandard II – DiagnosisStandard III – Outcome IdentificationStandard IV – PlanningStandard V – ImplementationStandard V includes milieu therapy, promotion of self-care activities, psychobiological interventions, health teaching, case management, health promotion and health maintenance

Objective 5Objective 5

Describing the composition of the Board of Mental Health in Nebraska and Iowa

Iowa’s mental health committals are handled by the county court in which the ill individual resides.

The Board of Mental Health in Nebraska consists of:

2 licensed mental health practitioners 2 certified marriage and family therapists 2 certified master social workers 2 certified professional counselors 2 public membersMembers of the BOMH serve for 5 years,

with no more than 2 consecutive 5-year terms.

At least one member of the board must be a member of a racial or ethnic minority.

The professional members of Nebraska’s BOMH must meet the following requirements:

Be actively engaged in the practice of his/her profession

Be working in his/her profession within the State of Nebraska

Be working under a license issued in this state

Have a 5-year history of working in his/her profession just preceding the appointment

The public members of Nebraska’s BOMH must meet the following requirements:

Be a resident of this state

Attained the age of majority

Represent the interests and viewpoints of consumers

Not be a present or former member of a credentialed profession, an employee of a member of a credentialed profession, or an immediate family or household member of any person presently regulated by such board

Objective 6Objective 6

Examining psychiatric client rights

Universal Bill of Rights for Mental Health Patients

Mental Health Systems Act of 1980

Right to the least restrictive treatment alternative

Right to informed consent

Right to refuse treatment

Right to confidentiality

Right to keep personal items

Right to the least restrictive treatment alternative

The nurse must attempt to provide treatment in a manner that least restricts freedom

Right to informed consent

Informed consent is the client’s permission to perform treatment

Legal liability for informed consent lies with the physician

The nurse acts as the client’s advocate to ensure informed consent was obtained

Right to refuse treatment

The patient has the right to refuse treatment to the extent permitted by law, and to be informed of the medical consequences of his or her action

Right to confidentiality

Pt’s privacy is protected by Amendments IV, V, and XIV

Protection of client records and communications per state statute

Right to keep personal items

People in a hospital or other treatment facility retain the right to keep their personal possessions

Items must be protected and returned upon release from the facility

Exceptions include:– the belonging poses a serious threat to self

or others– items that may be dangerous would be held

in a secure place during hospitalization– personal items must be returned to the

client upon release from the facility– (each facility has own guidelines regarding

confiscated illegal items)

Psychiatric patients have the right to freedom from restraint or seclusion except in an emergency situation:

Restraints or seclusion are used for an individual whose behavior is out of

control and who poses an inherent risk to the physical safety and psychological well-being of the individual and staff or

others.

Restraints or seclusion are never used for punishment or for the convenience of staff. Mechanical Restraints

– set of leather straps 5-point maximum use 2-point minimum use

– used to restrain the extremities of the individual

– individual is always in seclusion if in restraints Physical Restraints

– Seclusion (solitary confinement in a locked room)– Holding (used with smaller children)

Requires 1:1 supervision

Restraints and Seclusion Guidelines

Restraints or seclusion can be initiated without a physician’s order in an emergency

Physician must be notified for an order within 1 hour of initiation

Renewal of restraint or seclusion orders– Every 4 hours for adults– Every 2 hours for children 9 years and older– Every 1 hour for children younger than age 9

Restraints and Seclusion Guidelines (cont’d)

In-person evaluation of individual in restraints or seclusion by the physician

– Within 4 hours of initiating restraints or seclusion for an adult– Within 2 hours of initiating restraints or seclusion for a child

In-person re-evaluation of individual in restraints or seclusion by the physician

– Every 8 hours for an adult– Every 4 hours for a child

The nurse must assess and document circulation, respiration, nutrition, hydration, and elimination every 15 minutes

Concepts related to the Right to Freedom False imprisonment = the deliberate and unauthorized confinement of a person within fixed limits (can be verbal or physical)

– may include taking a client’s clothes for purposes of detainment against his or her will

Assault = an act that results in a person’s genuine fear and apprehension that he or she will be touched without consent Battery = the touching of another person without consent (harm or injury may or may not occur

Major Elements of Informed Consent Knowledge Competency Free willTreatment may be performed without obtaining informed consent under these conditions: The client is mentally incompetent to make a decision and treatment is necessary to preserve life or avoid serious harm Refusal endangers the life or health of another An emergency situation Client is a minor Therapeutic privilege (full disclosure would complicate treatment, cause severe psychological harm, or be so upsetting as to render a rational decision impossible)

Objective 7Objective 7

Discussing confidentiality in psychiatric care

Health Insurance Portability and Accountability Act (HIPAA) of 1996

The individual has the right to access his/her medical records The individual has the right to have corrections made to his/her medical records The individual has the right to decide with whom his/her medical information may be shared

Breach of Confidentiality Revealing aspects about a client’s case Revealing that an individual has been hospitalized

Defamation of Character

Sharing of malicious and false information that is detrimental to an individual’s reputation Client may seek legal restitution if making the information known resulted in harm Libel = information shared in writing Slander = information shared orally

Invasion of Privacy

Searching a client without probable cause

Objective 8Objective 8

Discussing criteria for hospitalization of a mentally ill

client

In order to be considered eligible for admission to an acute inpatient psychiatric unit, an individual must meet one or more of the following criteria:

The client is an imminent threat to himself/herself

The client poses an imminent threat to the safety and/or well-being of others

The client is unable to provide for his/her basic needs in spite of having adequate resources

The client is out of control

Objective 9Objective 9

Comparing voluntary hospitalization, involuntary

hospitalization, and involuntary commitment

Voluntary Hospitalization Admission process similar to medical hospitalization Patient may stay as long as treatment is deemed necessary Patient can leave at any time

Involuntary Hospitalization Client is hospitalized without consent Situation must be considered an emergency Client receives observation and treatment for mental illness May occur when an individual is unable to take care of his/her basic needs in spite of having adequate resources to do so

Involuntary CommitmentIn the State of Nebraska, an individual can be involuntarily committed subject to due process and as a result of being a danger to self or others as manifested by:

Recent threats or acts of violence

Substantial risk of serious harm evidenced by inability to provide for basic human needs, including food, clothing, shelter, essential medical care, or personal safety

Types of Involuntary Commitment

“Voluntary” commitment via a guardian

Emergency Protective Custody (EPC)

Physician hold

Board of Mental Health hold

Board of Mental Health commitment

“Voluntary” Commitment via a Guardian Guardian may voluntarily commit ward to a mental health treatment facility No due process required

Emergency Protective Custody (EPC) Police custody 36-hour time limit Terminates automatically or by county attorney intervention

Physician Hold May follow EPC or voluntary admission 48-hour time limit

Board of Mental Health (BOMH) Hold

Petition can be filed by anyone at any time Petition must include sufficient documentation that an individual is at imminent risk of harming self/others Once approved, client brought to hospital/psychiatric facility

– BOMH hearing set for 7 calendar days– Client served with copy of BOMH petition– Client has the right to attend hearing and be represented by an attorney

Physician can drop petition after assessment of client with approval from the county attorney

Board of Mental Health (BOMH) Commitment

BOMH determines whether a client should be involuntarily committed to inpatient or outpatient treatment during the BOMH hearing following the filing and approval of the petition BOMH treatment plan must be approved during the process of the hearing as this directs client’s care throughout his/her commitment Committal must be reviewed periodically, as well as upon appeal by client/client’s attorney or physician Ultimate goal of the BOMH is to use the least restrictive means possible to ensure the client receives necessary treatment