Selected Issues in Mental Health Nursing ChiaLing Mao

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Selected Issues in Mental Health Nursing
Chia-Ling Mao
Marilyn Tagatac

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Introduction

• Significance
• Safety self clients
• Quality of care
• Background
• Extended roles of the nurse
• Myth of psychiatric treatment
• Patients right
• Ethical theories

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Statutory and professional standards

• Standard of nursing practice written document
  outlines minimum expectations for safe nursing
  practice
• Nurse practice act defines the scope limit of
  nursing practice
• Code of ethics guideline for nurses regarding
  ethical conduct.
• Legislation - minimum expectation

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Critical Thinking in Mental Health Nursing

• 1. Parents demand that their child on a 72-hour
  hold, as a danger to self, be released to their
  custody to be evaluated by their childs
  psychiatrist. You respond?
• 2. When would you administer medications without
  a patient consent?
• 3. Which is least restrictive - chemical or
  physical restraint?

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How would you advise?

• 911 - welfare check
• Mobile crisis team, Crisis Intervention Team
• 72-hour hold criteria, probable cause
• Danger to self
• Danger to others
• Gravely disabled

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Legal Issues

• Civil Rights Commitment - Involuntary Commitment
• Californias LPS Act (1969)
• Criteria - Dangerous to self (DS)
• Dangerous to others (DO)
• Gravely Disabled (GD)
• Criteria is not the same in all states
• What is considered GD?

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Patients Legal Status

• Involuntary 72-hour hold, 5150
• designated person authorized by law
• Tarasoff Law duty to warn of threatened suicide
  or harm to others
• 14-day, 180-day certification
• Conservatorship/ Public Guardian
• pt. unable to make own decisions

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Competence Determination Act

• Alertness, attentiveness
• ability to process info
• thought processes
• ability to modulate mood and effect

• Mini-Mental Status
• Examination
• Orientation
• Registration
• Recall
• Attention/ Calculation
• Language

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Patients Rights

• Confidentiality of records
• Least restrictive alternative to treatment
• Right to give or refuse consent for treatment
• What constitutes dangerous behavior that require
  meds to be given without patient consent?
• Freedom from restraint and seclusion
• Which is least restrictive - chemical or physical
  restraint?

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Violence

• A social problem that requires a public health
  approach - ecological model
• Macro-system accounts for societal beliefs and
  cultural norms
• Micro-system formal and informal social
  structures
• Exosystem community level of influence
• Ontogenic development individual factors
  including biological neurodevlopmental factors
• Strongest predictor - a history of self-harm or
  injury to others

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Staff Rationale

• Chemical Restraints
• less physically restrictive
• longer-lasting effects
• allows pts to participate in other tx modalities
• more easily given
• (Chemical restraint is a contradiction.)

• Physical Restraints
• more immediate controlsafety
• less invasive than medication
• allows patient to regain own control
• therapeutic choice for substance abuse

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Least Restrictive Alternatives

• Restraints have a negative influence on
  caregiving process. Dysfunctional - pt
  disempowerment (JanelliKanski, 1994)
• Utilize hierarchical interventions. Physical
  restraint is last alternative.
• Restraint to be used is based upon the individual
  client.
• Differing views result in contrasting staff
  interventions

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Hierarchy of Least Restrictive Intervention

• 11 interaction/verbal redirection
• Decreased external stimuli (quiet time)
• PRN meds
• open seclusion
• locked seclusion (emergent meds)
• 2- point restraints
• 4-point restraints
• DOCUMENTATION is critical

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Being Restrained a study of power and
powerlessness (Johnson, 1998)

• Pt responses anger, fear, resistance,
  humiliation, demoralization, discomfort,
  resignation, denial, and agreement
• We assume restrained pts are feeling frightened
  and out of control that pts will feel relieved
  and safe with external limits.

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Power Struggles

• Take away all power and control dehumanizing
  -basic protective human instinct taken away
• We need to remember that restraining another
  person is a practice that renders another human
  being helpless. We need to use it as a last
  resort.

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Violence in the Workplace

• Reflects increasing violence in society incident
  is high and vastly under reported
• 75 of all psychiatric nursing staff assaulted at
  least once (Poster, 1996)
• Shorter hospital stays, sicker pts, budget cuts,
  understaffing, less community resources.

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Violence and Nurses

• Conflict between the roles of victim and
  caregiver
• Victims need time to pull back - anxiety, anger,
  vulnerability, PTSD, coping skills
• wholistic approach to the problem examine the
  interaction of the assailant, others involved,
  the environment (staffing levels)
• clinical, educational, administrative support

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Unit Milieu and Violence

• Overcrowding, staff inexperience,
  provoking/controlling, poor limit setting,
  inconsistency
• Staff training critical - mandatory team effort,
  coordination
• Staff need to be aware of their own feelings,
  responses impact of staff behavior on pts.
• Hypervigilant about personal safety

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The Aggressive Patient

• Interventions
• Policy and practice JCAHO SR Standards
• Hierarchy of least restrictive intervention
• Staff aggressive physical response not allowed
• Goals
• Safe environment for everyone.
• Advocate and protect patient rights.

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Risk Factor for Aggression

• Major psychiatric disorders
• Personality disorders
• Med noncompliance
• Dual diagnosis

• Young males
• Low socioeconomic status
• Weapons
• Social isolation
• Criminal history
• History of violence
• Substance abuse

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Agitation, Aggression, Violence

• Agitation - hyperverbal, loud, pressured speech,
  pacing, hypervigilant, clenched fists,
  threatening stance, profanity
• Aggression - threat directed toward others
  (verbal, physical), assault
• Violence - outburst of physical force that
  abuses, injures, others or objects.
• Be able to anticipate reaction/bhv to possibly
  prevent agitation leading to aggression.

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Causes of Threatening Behaviors

• 1. Fear
• 2. Frustration
• 3. Manipulation
• 4. Intimidation
• Mental illness may impact the way person
• perceives and responds to the environment.

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Assault Cycle

• Triggering
• Escalation
• Crisis
• Recovery/depression phases
• (Table 14-1 Assault Cycle)
• (Table 14-2 Interventions based on the assault
  cycle)

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The 10 de-escalation commandments

• Be non-provocative make contact, be calm,
  empathic
• Respect personal space
• Establish verbal contact one communicator
• Be concise get the attention but not confuse
• Identify the clients wants and feelings
  interpretation and validation

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de-escalation commandments (II)

• 6. Lay down the law set limit, use ()
  reinforcement
• 7. Listen no argue, redirect to the issue at
  hand
• 8. Agree or agree to disagree no power struggle
• 9. Have a strategic plan, a moderate show of
  force and be prepared to use it team
  collaboration
• 10. Debrief with patient and staff

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Self-Protection

• Self control
• Be aware of your own feelings fight or flight
  press your buttons
• Self awareness/
• assessment
• Physical/emotional balance

• Effective Evasion
• Observation strategy
• Position, distance self
• Allow an exit
• Never deal with an
• agitated client alone
• Remove self summon
• help

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Nursing Interventionswith the Agitated Patient

• Meds PRN
• Anxiolytics - Ativan
• Typical/Atypical Antipsychotics - Haldol
  (po/IM), Risperidone, Zyprexa
• Communication Strategies
• Tips for Crisis Intervention

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Forensic client

• Evaluate defendants competency to stand trial
  administer concomitant pretrial treatment

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Other violence

• Youth violence
• Intimate partner violence (IPV)
• Rape
• Child abuse
• Elder abuse

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Rape

• Rape is a crime
• Rape is under reported
• Perpetrator
• Stranger 15
• Date rape and acquaintance rape
• Sense of betrayal, self-blaming,
• Marital rape ( a crime, but with evidence of
  force)

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Rape trauma syndrome The first phase

• Acute phase of disorganization days or weeks
• Response to rape, fear, anxiety, disbelief,
  anger, shock
• Physical signs- Sleep disturbance, nightmare,
  pains, body aches, fatigue, loss of appetite
• Ritual behaviors associate with ensuring safety
• Hyperalertness to potential danger
• Open response Vs. stoic response
• Irritability, difficulty concentrating, obsessive
  thought, tearfulness, anger, humiliation, guilt,
  shame

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Rape trauma syndrome The second phase

• A long-term reorganization phase integration
  and resolution of the experience
• Goal regaining empowerment and reconnecting
  with others learning new ways to feel safe again
  and to manage disturbing symptoms
• PTSD others ie depression, anxiety disorders,
  substance abuse, sexual dysfunction disorders,
  dissociative identity disorder, borderline
  personality disorder

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Treatment for rape victims

• Psychopharmacologic interventions
• Antidepressant
• Antianxiety med
• Atypical antipsychotics
• Psychological interventions
• Behavioral therapy
• Cognitive therapy
• Individual therapy
• Group therapy, family therapy
• Biofeedback, relaxation training, assertiveness,
  hypnosis, body work (dance, massage, yoga

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Ethical theories

• Utilitarianism
• Deontology
• Autonomy
• Beneficence
• Non malificence
• Fidelity
• Veracity
• Paternalism
• Justice

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Everyday ethics

• Interpersonal relationship - respect, caring
• Unconditional positive regard
• Request the search for human dignity

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