Introduction to

Psychiatric Nursing
Module
2:
Concepts
RNSG 2213

History Concepts

How were mentally ill treated prior to1790s?

Banishment
Confinement
What were attitudes toward them?
Possessed by the devil
Lacked basic human qualities

St. Mary of Bethlehem Hospital,

London
(Bedlam) Opened to lunatics
1403

Visitors pay for entertainment

History Concepts

Period of Enlightenment begins in 1790s

Concept of Asylum (sanctuary):

If we treat patients humanely and

respectfully, they will improve.
Mental illness worsens with stress

First mental hospitals (asylums) in US in 1820s

History Concepts

Who was Dorthea Dix?

A nurse who was one of the first major

reformers in the United States.
Helped develop the concept of an asylum
Direct role in opening 32 state hospitals

Dorthea Dix Asylum in North

Carolina

Austin, Texas
State Insane
Asylum 1851

Era of Psychotropic Drugs

Medications first available in 1950s, i.e.

chlorpromazine (Thorazine) for
Schizophrenia, Lithium for Mania
Hope for previously incurable mental
illnesses and enhanced quality of life.

Community Mental Health

Movement
Response to the overcrowding and bureaucracy of public

mental hospitals.
Chronically mentally ill warehoused and often abused,
neglected
1963 Community Mental Health Act
Concept: Patients can be treated better, cheaper in
community
Massive deinstitutionalization: All State Hospitals in some
states closed
Results: Increased acuity and strain on
emergency services, increased number
of homeless mentally ill

ETHICAL ASPECTS: SOCIAL

VALUES
(Consider what effect each of these
values has on mental health care)

Individual Freedom
Money
Paternalism vs Libertarianism

Paternalism believes that an authority knows

what is best for you
Libertarianism believes that the individual knows
what is best for them

No other area of nursing is so affected by social

values as psychiatric nursing

A Nurse Needs to Know

About:

How to adapt legal principles to mental health

settings:

safeguarding nursing practice from charges of

negligence, false imprisonment, assault, or battery

DUTY TO WARN

Mental health professionals must warn others of a

clients threat of suicide or of harm to self or
others

Rights of
Psychiatric/Mental Health
Right to refuse treatment
Patients

Right to informed consent ( and the right to

know about rights)
Right to confidentiality
Right to receive visitors and telephone
calls
Right to be treated with respect
Right to be treated in the least restrictive
environment

Client Rights

Concept of Least Restrictive Environment:

Should guide nursing decisions

Seclusion is used when the person is a danger to
others
Restraint is used when the person is a danger to
self
Never used to get a patient to comply

Rights of Mentally Ill

Patients

Basic Needs:

Warmth: clothing a blanket

Food
Access to the outdoors

Contact with family, legal representative

Do NOT have right to all possessions
(When can access to possessions be restricted?)

Legal Aspects:
Commitments
(As Applied under Texas
Law)by the Texas Mental
Mental illness as defined

Health Code
Mental illness is a disease or condition which
either:

Substantially impairs the persons thought,

perception of reality, emotional process
and/or
Grossly impairs behavior as manifested by a
recent event of disturbed behavior (Gravely
disabled)

Commitments
Voluntary Commitment
A person 16 years of age or over signs
themselves in for admission. Person is
advised of their rights under the code.
4 Hour Rule: If a patient changes their mind
about being in the hospital, psychiatrist has 4
hours to file for a commitment.
Signs a consent for treatment.

Commitments, contd

Most commitments are voluntary where the

individual or the therapist request admission
and the patient meets criteria for admission
The patient must sign consents for all
psychotropic medications. Refusal to sign
these consents means the medications can
NOT be administered

Involuntary Commitments
Emergency Mental Illness Commitment
Allows Mental Health Deputies (Crisis
Intervention Team) to pick up a person who
presents an IMMINENT DANGER TO SELF
OR OTHERS and is Gravely Disabled
and bring them into custody for 24 HOURS.
MD can begin commitment procedures (file)
at that time.

Involuntary Commitments,
contd
Order of Protective Custody (OPC)
Commitment must be accompanied by a
medical certificate, which states that the
physician has examined the patient within 24
hours. Filed at the County Clerks Office.
Probable Cause Hearing within 72 hrs.
Pt. can be committed for 14 days.

Involuntary Commitments,
contd

Temporary Commitment
Papers must be filed with the Court
Hearing before a judge with physician and patient
present.
Must prove Danger to self or others or meets the
deterioration standard
Can be committed UP TO 90 DAYS.
May be discharged any time staff believes pt. is
ready.
May change to Outpatient Commitment

Involuntary Commitments,
contd
Extended Mental Health Commitment

Very strong evidence needed

Commitment is up to 1 year.

Last but not least . . . .

All involuntary commitments can include

court-ordered medications

All commitments discussed previously can

apply to Chemical Dependency

TREATMENT SETTINGS
AND THE CONTINUUM OF
CARE

Where do we see the mentally ill being

treated?
How do individuals enter the mental health
system?
Why is discharge planning so important?

PSYCHOTHERAPEUTIC
MANAGEMENT

TOOLS ARE:
SELF DRUGS
ENVIRONMENT
Therapeutic Use of SELF (Nurse-Client
Relationship)
DRUGS: Psychopharmacology
ENVIRONMENT: Therapeutic Milieu

NURSE ON THE MENTAL

HEALTH TEAM

Mental Health Team:

Psychiatrist
Nursing staff: includes licensed nurse, tech
Psychiatric Social Worker
Psychologist
Therapeutic Recreation and Expressive Arts
personnel
Client and Family
Other: Substance abuse counselor, employment
specialist, dietician, etc.