The Birth of Community Mental Health (contd) Community Mental Health Centers Act passed by Congress in 1963

Expanded community care for the prevention of serious mental illness with early intervention and outpatient therapy Provided for reimbursement of mental health services through Medicare and Medicaid Resulted in the deinstitutionalization of the mentally ill
State mental hospitals were closed Individuals diagnosed with a mental illness were discharged to the community for ongoing care

Cause of Revolving Door in Mental Health

Cost of care for hospitalized psychiatric clients continue to rise. Individuals with severe mental illness had no place to go when their symptoms became worst except back to the hospital. Lack of funding for adequate community services

Community Mental Health & the Client

A change in focus of psychiatric health care from individual to individual interaction with the environment /community The nurse can help to implement this change in societal beliefs and attitudes about mental health Comprehensive care is delivered in the home or environment, allowing for more patient freedom. CMHCs were designed to provide prevention, early treatment, and continuity of care in communities, promoting social integration of people with mental health needs.

Goals of CMHC
Promote and maintain health and prevent disease: Help people recover from their illness or comes to term with their illness in order to maximize their life potential. primary goal is prevention, this includes primary, secondary and tertiary prevention

Primary Prevention
Primary prevention aims to prevent the disease from occurring. So primary prevention reduces both the incidence and prevalence of a disease. Encouraging people to protect themselves from the sun's ultraviolet rays is an example of primary prevention of skin cancer.

Secondary Prevention
Secondary prevention is usedafter the disease has occurred, but before the person notices that anything is wrong. A doctor checking for suspicious skin growths is an example of secondary prevention of skin cancer. The goal of secondary prevention is to find and treat disease early. In many cases, the disease can be cured.

Tertiary Prevention
Tertiary prevention targets the person who already has symptoms of the disease The goals of tertiary prevention are: prevent damage and pain from the disease slow down the disease prevent the disease from causing other problems (These are called "complications.")

Tertiary Prevention (Contd)

give better care to people with the disease make people with the disease healthy again and able to do what they used to do Developing better treatments for melanoma is an example of tertiary prevention. Other examples include better surgeries, new medicines, rehabilitation etc.

Characteristics Mental Health

Reality orientation: one characteristic of
mental health is that a person is able to distinguish facts from fantasy, real world from a dream world. Must have ability to perceive reality without distortions, have a good sense of consequences of your actions.

Self awareness/Introspection
Introspection is to look inward in an effort toward self understanding. Recognize own feelings, possible prejudices Two of Socrates most well-known quotes are "know thyself" and "the unexamined life is not worth living." Introspection helps the nurse identify thoughts and feelings helps the nurse learn about his/her behavior prevent barrier to communication and understanding of patients behavior

What is Introspection?
Defined as: the observation or examination of one's own mental and emotional state, mental processes, etc.; the act of looking within oneself. This implies that through introspection we become self-aware. The nurse needs to be aware of, understand, and consider his/her own feelings/behavior in order to remain objective and to promote therapeutic relationship.

What defines a social relationship?

A social relationship is reciprocal, that is both people expect to get their needs met. Have something in common It involves friendship, companionship. Boundaries are not as defined There are not necessarily goals to be met We may give advice, have small talk

Therapeutic Relationship (Contd)

Therapeutic Relationship
Goal specific Client centered Responsibility and reliability of nurse Professional boundaries Clients gain only Clients needs are foremost Open to supervision.

Introspection (Contd)
Assists the nurse in identifying her thoughts and feelings and to learn about his/her behavior. It promotes understanding of clients behavior by preventing barriers to interpretation.

Establishing Therapeutic Relationship

Establishing a Therapeutic Relationship: Orientation Phase

Meeting nurse, client Establishment of roles Discussion of purposes, parameters of future meetings Clarification of expectations Identification of clients problems Nurse-client contracts/confidentiality, duty to warn/self-disclosure

Behavior of Client During Orientation Phase

Client May Be distrustful, superficial, quiet, avoid discussion of issues Resistance Exaggerate problems Have rambling speech/anxiety Act out

Establishing the Therapeutic Relationship: Working Phase

Problem identification: issues or concerns identified by client; examination of clients feelings and responses. During this phase trust begins to develop and the patient begins to respond selectively to person who seem to offer help. The patient begin to identify with the nurse and identify problems, which can be worked on

Therapeutic Roles of the Nurse in a Relationship

Teacher identifying needs of pt.(coping, problem solving, medication regimen, community resources)

Definition of a Scientific Theory

A theory comprises of a collection of concepts used to explain observations

Interpersonal/Social Psychology Theories

Harry Stack Sullivan, a psychiatrist He thought that inadequate or non-satisfying relationship produce anxiety and is the basis for all emotional problems Sullivan thought that human nature must be understood from the vantage point of interpersonal relations. He believed that the development of self concept is influence by reflected appraisal. The term reflected appraisal refers to a process where we imagine how other people see us. The way we believe others perceive us is the way we perceive ourselves. The self is the sum of reflected appraisals of others.

Erik Erikson
The new Ego. Erikson believed that the Ego Freud described was far more than just a mediator between the superego and the id. Erikson saw the Egos main job was to establish and maintain a sense of identity. (a sense of belonging). Erikson developed stages of psychosocial development. The inability to complete the first stage of Trust Vs. Mistrust may result in anxiety, heightened insecurities, and an over feeling of mistrust in the world around him/her.

Eriksons Theory
Autonomy vs. Shame & Doubt This is the stage of I am what I can do. The child ego skills continue to develop along with his/her will power and self control. If a person develops a low self-esteem accompanied by secretiveness. This person has not completed the autonomy vs. shame & doubt stage and needs to complete this stage before moving on to the other stage of development. Initiative vs. Guilt (preschool) development of conscience learning to manage conflict and anxiety. Continuation of autonomy.

Eriksons Theory
Industry versus inferiority
Taking pleasures in his/her competence. Developing confidence in his/her abilities. Failure to complete this stage the child becomes a conformist and thoughtless person who others exploit . The person develops an inferiority complex.

Identify vs. role confusion (adolescence) Prior to this stage, development depends on what is done to the person.

Defense Mechanism
An ego defense mechanism becomes pathological only when its persistent use leads to maladaptive behavior such that the physical and/or mental health of the individual is adversely affected. The purpose of the ego defense mechanisms is to protect the mind/self/ego from anxiety.

Levels of Anxiety
Definition of Anxiety: is a state of dread, unpleasant feeling which leads to increased helpless feeling. There are four levels of anxiety
Mild, Moderate, Severe,Panic

The nurse intervention must include: Reducing the anxiety to a lower level Observing the anxiety and identify the level Inform the patient what is being done.

Levels of Anxiety
Mild
Associated with the tension of everyday life The individual is alert The perceptual field is increased Ability to learn is increased Effective problem solving S & S: Restlessness, fidgeting, buttterflies, sleep disturbance, hypersensitive to noise.
MENTAL HEALTH NURSING: Psychiatric Disorders

Anxiety Levels
Mild (Contd) Intervention: generally requires no direct intervention. keep the clients anxiety level from escalating. Assist the client to identify the event or situation that preceded the symptoms of anxiety. Help the client to problem solve. Assist the client to slow breathing rate and depth. On Long term basis assist client to problem solve to decrease stress and anxiety Assess the thoughts and feelings prior to the anxiety (i.e., what cause the anxiety). Note anxiety is very contagious Teaching can be very effective when there is mild anxiety.

Obsessive-Compulsive Disorder
Obsessions ((the thinking aspect) are recurrent, persistent, intrusive, and unwanted thoughts, images,or impulses that cause marked anxiety and interfere with interpersonal, social, or occupational functioning. e.g. obsessed with contamination Compulsions (the acting aspect) are ritualistic or repetitive behaviors or mental acts that a person carries out continuously in an attempt to neutralize anxiety.
e.g. compulsion - repetitive hand washing

Nursing Process for OCD Intervention (Contd)

Assist client to identify events that increase their rituals. Plan schedule around clients rituals Allow the client to perform the rituals but set limits. Be supportive to the client but limit the behavior Protect client from harmful rituals e.g., give gloves if the ritual is washing hands 90 times/day.

OCD (Contd)
Important Nursing Implication: The nurse must understand that the client recognize that his/her symptoms are unacceptable or foolish

SOMATOFORM DISORDERS
Is a mental disorder characterized by physical symptoms that suggest a medical condition. Upon physical examination, the findings are negative. Usually occurs before age 30. Client will talk about multiple vague physical complaints involving various parts of the body or various body systems. It is a chronic disorder

SOMATOFORM DISORDERS
Onset and Clinical Course: Symptoms usually onset in adolescence or early adulthood All the somatoform disorders are either chronic or recurrent Clients will go from one physician or clinic to another, or they may see multiple providers at once in an effort to obtain relief of symptoms

Somatoform Disorder
Intervention
Providing health teaching about the manifestation of the disorder Establishing a firm therapeutic alliance,( that is, a therapeutic relationship between the nurse/therapist and the client) Providing consistent reassurance to client Evaluate any new complaints

Conversion Disorder
Conversion disorder: unexplained deficits in sensory or motor function associated with psychological factors; The client display a lack of concern towards the physical symptoms. This is called la belle indifference. It is believed the physical symptoms may relieve anxiety and result in secondary gains in the form of sympathy and attention given by others. Primary gain is the relief of the emotional conflict/anxiety. Secondary gain is attention getting from others.

Somatoform Disorders -Nursing Conversion - Intervention

Meet the dependency needs that is, take care of client physical needs, eg. paralysis, perform ROM exercises of the limb. Never imply the symptoms are not real Dont react to the client indifference (la Belle Indifference) Teach stress reduction and assertiveness Be positive,make sure the client has a positive feelings and has positive outcomes.

SYMPTOMS OF SCHIZOPHRENIA

Types of symptoms
Negative symptoms Positive symptoms

SCHIZOPHRENIA NEGATIVE SYMPTOMS

Soft or negative symptoms include:
Affect is an outward manifestation of feelings or emotions.

Affect may be flat, blunt, labile inappropriate

Flat Affect Absence of any facial expression that would indicate emotions or mood.

Blunted Affect showing little or slow to respond with facial expression or no facial expression, voice monotone and no eye contact.

SCHIZOPHRENIA NEGATIVE SYMPTOMS (Contd)

Labile Affect rapidly changing, unstable and fluctuating emotions. May not fit the situation with content and speech Apathy (lack of emotional involvement) the patient has build a wall of indifference around himself. Inappropriate incongruency between the content of the speech and the expressed emotion.

SCHIZOPHRENIA POSITIVE SYMPTOMS - Defense Mechanism Projection

Hallucinations are distortions or exaggerations of perception in any of the senses that do not exist in realtiy. E.g. auditory hallucinations (hearing voices) visual hallucinations.

Hallucination and Defense Mechanism

Hallucination and defense mechanism projection:
Auditory hallucination means when there is no one talking to the patient, the patient perceives that some one else is talking to him. This is projection. The patient is projecting unacceptable feelings onto some one else. For example,The voice told me to kill the non believers..

SCHIZOPHRENIA POSITIVE SYMPTOMS (Contd)

Delusions - fixed false beliefs that have no basis in reality. Delusions defend against feelings, impulses or ideas that cause client anxiety. Delusions of being followed or watched are common, as are beliefs that comments, radio or TV programs, etc., are directing special messages directly to him/her. Eg. FBI Short term goal for delusional client: That the patient will report decreased frequency of delusional thoughts.

DELUSIONAL DISORDERS
Grandiose: People are convinced that they have some great talent or have made some important discovery. The grandiosity is a symptom of low self esteem.

Nursing Outcome: Patient self-esteem will increase

Antipsychotic Side Effects mostly of conventional antipsychotics drugs

Tardive dyskinesia (TDs) are involuntary movements of the tongue lips, (sucking, chewing and pursing movements of the tongue and mouth) face, trunk and extremities that occurs in patient treated with long term dopaminergic antagonist medications. Is common in patients with schizophrenia, schizoaffective d/o and bipolar disorder. Treatment: cogentin, haldol, benadryl

Schizophrenia Maintenance Therapy

Three antipsychotics meds are available in depot injection forms for maintenance therapy: Fluphenazine (Prolixin) in decanoate and enanthate preparations Haloperidol (Haldol) in decanoate RISPERDAL CONSTA The effects of the medications last from 2 to 4 weeks, eliminating the need for daily oral antipsychotic medication The medication improve patient compliance with treatment.

Antisocial Personality Disorder Characteristics

Very charming, cunning, superficial and very aggressive in meeting their needs. Adept at getting his way at the expense of others Feelings of boredom which leads to impulsivity and irresponsibility No blame or guilt acceptance Lack definite goals. Lots of restlessness Impaired ability to sustain long lasting close, warm responsible relationship.

Anti Social Personality D/O Intervention

Provide structure and limit setting Point out the unacceptable behavior. Be direct and consistent about the statement of the behavior. Point out the consequences of the unacceptable behavior and follow through consistently.

Characteristics Of Client With Personality Disorder

Personality Disorder is characterized by inflexible behavior pattern that causes problem in functioning and relationship. It is a maladaptation to interpersonal interaction and social environment or context (i.e. how the client viewed things, objects, situations)

Personality Disorders
Borderline Personality Disorder Assessment:
Patients often has dysphoric mood( feeling of unhappiness, emotional lability) Dependency Display impulsive behavior Splitting, Over- idealization and devaluing Experience suicidal feelings Complains of feeling of emptiness, suspiciousness and loneliness

Borderline Personality Disorder (Contd)

Intervention
Monitor for suicidal gestures because client generally feel abandon and suicidality is a great risk factor

Individual Psychotherapy
Modifies a persons feelings, attitudes, and behavior Involves one-on-one work between patient and therapist. Allows the patient to have the full attention of the therapist Is limited - it does not allow the therapist an opportunity to observe the patient within social or family relationships.

ETOH Withdrawal
Usually begins 4-12 hours after cessation or marked reduction of ETOH. Symptoms: coarse hand tremors, sweating, elevated pulse and BP, insomnia, anxiety, N&V May progress to hallucination, seizures, illusion, gross tremors and delirium tremens (DTs) Treatment: benzodiazepines to prevent seizures

Major Depression Disorder

Involves 2 or more weeks of sad mood, lack of interest in life activities (anhedonia), and at least four (4) other symptoms:
Changes in appetite or weight, sleep, or psychomotor activity Decreased energy (persistent fatigue) Feelings of worthlessness, hopelessness helplessness Persistent feeling of guilt or self-criticism Persistent sadness

Major Depressive Disorder

Intervention Provide for the clients safety and the safety of others Promote a therapeutic relationship by maintaining planned contact with patient. Establish daily schedule of activities Structure activities to facilitate completion of one specific task. Sit silently with patient when patient is not too communicative Promote activities of daily living and physical care

Treatment (Contd)
TCAs: amitriptyline (elavil), imipramine (tofranil), moderate and severe depression. Their onset of action is 1-4 weeks. i.e., they take 1-4 weeks before the client symptoms begin to decrease. Have anticholinergic side effects: blurred vision, dry mouth, constipation). MAOIs (marplan, parnate, nardil) used infrequently because interaction with tyramine causes hypertensive crisis. TCAs and MAOIs cannot be given concurrently The primary side effect is hypertensive crisis if the drug is taken with food containing tyramine

Bipolar Disorder
Assessment Some people with mania exhibit psychoses e.g delusions (unshakable beliefs in something untrue) and/or hallucinations. Some get hostile and aggressive if they needs are not met. Hyperactive, disorganized and has an elevated mood. Easily stimulated by what is going on around him/her. For how much the client is eating and sleeping

Bipolar Disorder (Contd)

Assessment
Major symptoms of mania include: Inflated self-esteem or grandiosity Decreased need for sleep Psychomotor agitation Pressured speech Flight of ideas Distractibility Euphoria, labile mood

Bipolar - Treatment
LITHIUM CARBONATE Treatment and Prognosis - Medication Treatment involves a lifetime regimen of medications Lithium; regular monitoring of serum lithium levels is needed. Lithium not only competes for salt receptor sites but also affects calcium, potassium and magnesium ion as well as glucose metabolism. Therapeutic level 0.5-1.5 mEq/L

Bipolar Treatment (Contd)

Lithium (Contd) Nursing Implication: Teach patient to maintain adequate salt in the diet. If patient is toxic, hold medication and report to MD

Anticonvulsant drugs are used for their mood-stabilizing effects: Depakote therapeutic level 50-100 mcg/ml. Side effect: Weight gain, agranulocytosis
Tegretol therapeutic level 6-12 mcg/ml Side effects:agranulocytosis, thrombocytopenia, aplastic anemia

Bipolar Disorder
Intervention Providing for safety of client and others Meeting physiologic needs Providing therapeutic communication Promoting appropriate behaviors Managing medications Providing client and family teaching Set limits on intrusive or interruptive behaviors.