1.) the promotion and protection of mental health

2.) the prevention of mental disorders

3.) the treatment of mental disorders

4.) recovery and rehabilitation

initial & ongoing assessments

theraputic communication

facilitating family, group & community seminars

teaching

advocating

role modeling

mentoring

monitoring outcomes

relationship between the nurse & patient

theraputic communication

• helps to reduce the incidence
• community concept; involves lowering incedence by altering causative factors before they can do harm
• Deals with healthy minds and bodies (teaching mental health principles to groups, stress seminars, detriments of cigarettes & drug and alcohol abuse)

• helps to reduce prevelance
• providing comfort and arranging for safety for children who come to school with multiple bruises
• providing interventions that decrease stressors and anticipate crisis. Treat acute phase of illness as early as possible (home visits, suicide prevention, counciling & AA)

• reduce residual effects of mental disorder
• deals with existing crisis & reduces the consequences and level of disorder through promoting rehabilitation
• Rehab includes early d/c planning; follow up care; increase coping skills; supportive services & supervised living

1. when a person is unable to cognitively process info or to make decisions regarding their own welfare because of mental incompetence or severe psychosis
2. when a person is so severely depressed that they are intent on committing suicide

• Appearance
• Behavior
• Attitude
• Speech (quantity, quality & rate)
• Mood - have pt rate mood 0 (worst) - 10 (greatest)
• Affect - how we see pt; blunted (tiny smile); broad (happy to sad); flat (no expression);
• Perceptions - how is pt percieving things?
• Thoughts (form & content)
• Sensorium/cognition - alert/oriented? thinking process intact?
• Judgement - behavior (would they know not to drink steaming coffee?)
• Insight - what do they understand about illness & need for tx?
• Realiability

Assessment:

• physical
• psychiatric
• psychosocial
• mental status
• developmental
• cultural
• spiritual
• sexual

Lab results:

Abnormal BUN or electrolyte levels (r/t kidney disease) abnormal liver enzymes

Associated behaviors:

Agitation; depression & lethargy

Lab results:

abnormal glucose & insulin levels (r/t diabetes)

Associated behaviors:

changes in mood & sensorium; possible agitation

Lab results:

+ tox screen

Associated behaviors:

possible violence

an environment that is created and maintained to restore & promote optimal psychologic health and wellness

an environment that allows the mind & body to heal

Basic rules enforced by the nurse to maintain safe environment for staff, pt and visitors.

1. pts will not have access to harmful items such as sharps, belts and shoelaces.
2. pts will not have the means to harm themselves or others on unit
3. approved methods for managing pts who are high risk for aggressive behavior made available to staff.
4. theraputic communication skills, staff training and colaborative relationships among staff are essential

psychiatric dx

(clinical/mental disorder)

general medical condition

substance w/drawl

global assessment of functioning

measures pts overall functional state at the time of admission and within the past year.

• often cause personal suffering
• difficulty with relationships
• impaired functioning
• high costs to society & healthcare systems
• sometimes fatal w/high risk of suicide

often called "depression", and bipolar disorder are 2 severe mood disorders that pose signifigant public health problems that require attention and long-term tx

• person must be capable of informed consent; no max length but person may withdraw from tx totally or may refuse part of the tx program.
• Must give up to 72 hrs notice to withdraw from program.
• any person 14 or older; parent or guardian if under 14 may apple
• if 14-17, parent/guardian must be notified & informed of their right to object

302

120 hr emergency admission

• severe mental disability based upon clear & present danger to self or others.
• overt behaviors or threats with acts to further the threats occurring w/in past 30 days
• person may be treated against their will if it is to protect themselves or others
• may not exceed 120 hrs; pt may be subject to 303 committment
• pt may convert to voluntary status
• police, physicians or any other authorized persons may take pt to approved facility

303

20 day court ordered emergency tx

• after 24 hrs under a 302 a petition may be filed by staff for the need of extended tx
• director of facility or any other responsible person may apply
• may be committed to inpatient, part-care, out-patient care or d/c
• may not exceed 20 days.
• pt may be subject to 304B committment
• pt may convert to voluntary status

304B

90 day civil court committment

• court ordered involuntary tx for person presently subject to involuntary tx
• mentally ill; danger to self or others
• pt meets 302 & 303 criteria and needs extended tx
• may not exceed 90 days
• committment may be in-patient, partial hospitalization or out-patient
• pt may convert to voluntary status
• applied for by director of facility or county administrator

same as 304 except that committment period may be up to 180 days

pt must first be processed under 304

criminal committments which follow the 304 criteria,

purpose is to evaluate the competency to stand trial or to evaluate the person to assist the court in determining sentence

• severly mentally disabled and posing a clear or present danger to yourself or others
• may include actual or attempted self injury;
• attempted or inflicted serious bodily harm to another
• acting in a manner that indicates you cannot take care of yourself w/out assistance
• attempting suicide or showing high risk of suicide

• different from confidentiality
• enacted by statute to designated professionals such as clergy; attorneys; psychologists or physicians
• several states are now including nurses
• provisions allow for certain info given to professionals by pts to remain secret during any litigation
• only the pt can assert or waive this privilage
• statutes can exclude the mandatory reporting of child; elder; impaired adult; some cases of domestic violence; some communicable diseases that affect public safety and info that will prevent a felony from occurring

"protective privilage ends where the public peril begins"

The responsibility of a treating a mental health professional to notify and intended and identifiable victim

The new rules state that healthcare professionals were to only use S/R when less restrictive measures to ensure pt safety had failed such as talk to pt

• discipline
• punishment
• staff convenience
• coercion

frequent assessments for side effects and careful documentation of pts complaints related to side effects are essential

nurses need to carefully analyze and question the reason for the refusal of meds; is it because of the pt's denial of illness? symptomatology of the condition/ or because of the meds side effects or displeasure with tx?

• does the individual charged with the crime understand the criminal charges?
• is there an understanding of the legal process and the consequence of the charges?
• can the individual advise anattorney and defend the charges?

• relates to the state of mind at the time of the offense
• after a person is found not guilty by reason of insanity, they are usually hospitalized and sent to a psychiatric unit for evaluation of cmmitability 

• The theory that unconscious processes result in the expression of symptoms including depression and mania.
•  According to Freud, loss generates intense hostile feelings toward the lost object. The person then returns these feeligns inward onto self, thereby vreating guilt & loss of self-esteem.
• Thus depression is linked with loss and aggression.
• Psychodynamically, mania is a defense against depression

• Pt will deny feelings of anger; low self-esteem and worthlessness & reverses his/her affect so that there is a triumphant feeling of self confidence
• Mania represents a conquered superego with little inclination to control id impulses; however, over time, this distorted view of reality waivers and the pt demonstrates outward hostility toward others often focusing on the weakness of others that are similar to the internal weaknesses that they are avoiding

when individuals who are predisposed to depression with negative schemata encounter stress, the negative processing is activated resulting in depressive thinking differentiated among levels of cognition that influence depression:

automatic thoughts

schemata/assumptions

cognitive distortions

• thoughts that a person responds to but does not recognize as a basis for behavior & thinking.
• they form the persons perception of a situation (it is this perception rather than obejective facts, that result in emotional & behavioral responses)
• if the perceptions are distorted, inferences & responses will be maladaptive

• internal representations of the self and the world
• they facilitate info processing because the mind uses them to understand, code, and recall information

• negative, self-deprecating views of self
• pessimistic views of the world, which will result in life experiences being interpreted in a negative way
• the belief that negativity will continue into the future, which promotes a negative view of future events

this proposed triad is said to give rise to the development of depression

is demonstrated by the development of helplessness, apathy, powerlessness and depression

According to the original theory, uncontrollable stressful events that a person experiences result in a lack of motivation to act in response to the environment

this thoery was modified to specify that in the face of current and past experiences, individuals have the expectation that external events are uncontrollable; resulting in helplessness, passivity and sadness which leads to sx of depression

• a further revision of learned helplessness; a sufficient cause of depression
• the individuals inferred negative outcomes and negativity about the self are key elements of depression.

with the occurrence of an unpleasant event, persons who are at risk for depression and who have negative expectations attribute instability, globalization & excessive importance to those events

EX:

• instability -> a patient believes that she is not able to recover from divorce
• globalization -> now she feels her entire life is ruined
• importance -> her former marraige is the only focus of her life

• the lack of an intimate, confiding relationship with a sifnifigant other
• being unemployed
• the loss of one's mother before age 11

these factors are said to all contribute signifigantly to vulnerability for depression

1. early life stress such as loss or child abuse influence the development of depression most likely by disrupting the functioning of the HPA axis
2. the chronic hypersecretion of corticotropin-releasing factor and cortisol, and the autonomic nervous system activation that occurs during neurologically vulnerable times of development, sensitize physiologic stress responses & even generate brain changes

• assessment -> collects health data
• diagnosis -> analyzes assessment data
• outcome identification -> indetifies expected individualized outcomes for pt
• planning -> develops a plan that prescribes strategies & alternatives to attain expected outcomes
• implementation -> implements identified plan (coordination of care; health teaching & promotion; milieu therapy; pharmacologic & biologic therapies; prescriptive authority & tx; psychotherapy; consultation)
• evaluation -> evaluate progress toward attainment of expected outcomes
• quality of practice
• education
• professional practice evaluation
• collegiality -> interacts and contributes to the professional development of peers & colleagues
• collaboration -> with pts, family & others
• ethics
• research
• resource utilization
• leadership

i. self awareness (aware of own values & fears)

ii. gather data about the patient

iii. plan for the first meeting with pt

i. establish trust

ii. identify pt problems by exploring pt's thoughts, feeling and actions

iii. mutually formulate a contract with the pt

i. further defining the problem

ii. overcoming resistance behaviors

iii. exploring alternative solutions and development of new coping behaviors

iv. developing a realistic plan to meet identified health goals

i. review progress of relationship and attainment of goals

ii. mutually explore feeling of loss

• self
• trust
• respect
• genuiness
• empathy
• caring
• advocacy

WE NEVER GIVE ADVICE, ONLY OPTIONS & ALTERNATIVES!!

S -> sit facing patient

O -> observe an open posture

L -> lean forward

E -> eye contact

R -> relax

Psychiatric Assessment (mnemonics)

Always Send Mail Through Post Office

Appearance

Speech

Memory/Mood

Thoughts

Perception

Orientation

Behavior is the sum total of an individual’s thinking, feeling, and acting.

• It is anything about an individual
• It is a response to a stimulus, internal or external
• It is what we do about what we think or feel

Thinking

Feelin

Acting -> it is the acting that is most commonly meant when we use the word behavior. It implies acting out of a thought or a feeling...it is a human response

types of behavior

Reflex action

• neurological, no thinking involved
• impulse travels up the spinal cord and back again (touching a hot object and pulling away)

3 types of behavior

goal directed

a cyclic behavior involving the following:

need-> goal -> motivation -> action -> need accomplished

3 types of behavior

response to frustration

Normal Behavior is that course of action which is adapted to reality.

The "normal" person is able to modify his/her behavior through the learning process or life experience.

He/She has insight into cause and effect.

He/She is oriented to person, place, time, and situation

A positive state in which the person is responsible self-directed, and displays self-awareness.

Behavior is generally accepted within a group and is age related. It is an evolving process in which internal 2

demands and needs are harmonious with the reality of the environment

Purposefully (consciously or automatically (unconsciously) all people use mechanisms, techniques, and methods to attain and maintain "euthymia".

Ways to cope, to deal with life’s stressors, anxieties, etc. ….to feel better and to avoid psychological discomfort.

Knowledge of the defenses and an awareness of their use are important elements in assessment, diagnosis and treatment.

constant laughing, no laughing at all, withdrawing from others