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Keltner: Psychiatric Nursing, 5th Edition

Chapter 1: Introduction to Psychiatric Nursing
Chapter Focus
The human cost of psychiatric health care is great when one considers that mental and
addictive disorders affect more than 25% of Americans 18 years of age or older annually.
Consequently, psychiatric nurses provide some of the most important services in health
care today.

Four major benchmarks have contributed to the evolution of modern psychiatric care:
1. The Period of Enlightenment. This was initiated by the institution of humane care
advanced by Phillippe Pinel and William Tuke in 1793, which ultimately led to the
asylum (sanctuary) movement and, under the influence of Dorothea Dix, the
development of the state hospital system in the United States. It was during this
period that psychiatric nursing had its origins. Within 100 years of the origin of the
asylum movement, the hospitals created had evolved from places of refuge to places
of torment as the ideals of the reformers were lost on a new generation of caretakers.
2. The Period of Scientific Study. This was initiated by the work of Sigmund Freud,
Emil Kraepelin, Eugen Bleuler, and others who sought to understand the mind and
mental illness and who shifted the focus of care from sanctuary to treatment.
Therapies such as psychoanalysis, psychotherapy, and psychosurgery were developed
during this era. A classification of mental illness was developed.
3. The Period of Psychotropic Drugs. In the 1950s, this initiated a radical shift in the
care and treatment of mental illness. Patients who had seemed beyond help became
calmed and accessible. Dramatic “cures” took place. Hospital stays shortened, the
number of patients confined for long-term institutional care declined, and the
availability of community-based treatment increased.
4. The Period of Community Mental Health. This movement emerged from the
interaction of multiple dynamic forces, culminating in the enactment of federal
legislation that shifted funding from institutional care to extrainstitutional care (the
Community Mental Health Centers [CMHC] Act) and provided income for the
mentally disabled (currently, Supplemental Security Income [SSI] and Social Security
Disability Insurance [SSDI]). These shifts in funding, plus changes in commitment
laws that made involuntary commitment difficult, resulted in a rapid and dramatic
reduction of the state hospital population and the closure of many state hospitals.

Copyright © 2007 by Mosby, Inc., an affiliate of Elsevier Inc. All rights reserved.

Analyze the immediate and long-term effects of the community mental health movement. 3. and an increased complexity of problems presented by psychiatric patients (e. New challenges in psychiatric care have arisen: recidivism (reflected in increased admission rates). 8. Identify the specific strengths that enable psychiatric nurses to become effective in the new continuum of care. Identify the significant changes that occurred during the Period of the Enlightenment.. Describe the enormity of mental health concerns in both human and financial contexts. and substance abuse). expansion of the need for psychiatric services by general hospital inpatient psychiatric facilities and community agencies. assaultiveness.. 2. All rights reserved. the practice of psychiatric nursing has evolved from custodial care in the late nineteenth century to interdisciplinary collaboration in the treatment of the mentally ill. Parallel to developments in psychiatric treatment. Copyright © 2007 by Mosby. and from exclusive focus on the needs of psychotic individuals to the inclusion of the social and emotional needs of the worried well who are experiencing situational reactions. growing demands on general hospital emergency departments for crisis intervention and acute outpatient treatment. psychiatric nursing has gained direction. and professional accountability.Instructor's Manual 1-2 The advances and changes in psychiatric care have had far-reaching effects. Explain the impact of psychotropic drugs on psychiatric care. you should be able to: 1. mental health has become a concern for all.g. 4. . recognition. and psychiatric nursing education has advanced. 5. Psychiatric nurses will increasingly have a major role in resolving problems in mental health care and in developing a seamless continuum of care designed to meet the needs of the mentally ill. 7. Relate the contributions of early scientists to the current understanding of mental illness. an affiliate of Elsevier Inc. from dependent caregiver to independent practitioner. Key Terms asylum community mental health continuum of care deinstitutionalization homelessness psychotropic drugs Learning Objectives After reading this chapter. Inc. Social and emotional problems have become a legitimate focus for mental health care professionals. Most notably. Explain the history of psychiatry as a foundation for current psychiatric nursing practice. Through the influence of leaders such as Hildegarde Peplau. homelessness. 6. Describe the impact of the Decade of the Brain on psychiatric care.

homes with families.922 patients Hospitals Current population: 70. a place of maltreatment. Former patients live in nursing homes. All rights reserved. prisons. Depopulation of State Peak population (1955): 558. but deinstitutionalization movement was fostered by CMHC Act of 1963 and federal legislation that provided mentally disabled persons with an income while living in the community (SSI and SSDI). or on their Copyright © 2007 by Mosby.000 Many state hospitals have closed. sanctuary. Shifting the Cost of Mental State governments found that using federal monies Illness supplemented by state funds to provide aid to disabled mentally ill individuals resulted in huge cost savings. and confinement Important figures: Tuke: an English Quaker who started York Retreat Pinel: a Frenchman responsible for unchaining the mentally ill Asylum Two meanings: protection. Commitment laws underwent change out of new concern for individual civil rights. groups of similarly affected individuals. and abuse Dorothea Dix: developed concept of asylum in United States. Inc. . resulting in beginning of state hospital system Benchmark II: Period of Major scientists who emerged had an unquenchable curiosity Scientific Study about the mind and human behavior: Sigmund Freud (1856–1939): introduced psychoanalysis Emil Kraepelin (1856–1926): made detailed observations and descriptions of mentally ill patients Eugen Bleuler (1857–1939): coined term schizophrenia Benchmark III: Period of Approximate beginning: 1950s Psychotropic Drugs Chlorpromazine (Thorazine): first antipsychotic Imipramine (Tofranil): first tricyclic antidepressant (~1958) Lithium: introduced in late 1940s but not used in the United States until ~1970 Benchmark IV: Period of Convergence of forces led to mental health legislation: Community Mental Health  Public’s declining confidence in state hospital system  Failure of various treatment approaches  Progressive legislative climate  Faith in psychotropic drugs Negative effect: confusion about the boundaries of mental illness Deinstitutionalization Depopulation of State Hospitals began in 1955.Instructor's Manual Chapter Outline Benchmarks in Psychiatric History Benchmark I: Period of Enlightenment 1-3 Teaching Strategies Pre-Enlightenment: ABCs—assistance. an affiliate of Elsevier Inc. boarding homes. It became more difficult to effect involuntary commitment to a state hospital.. banishment. hopelessness.

As many as 20% to 25% of the homeless have a severe mental illness. as did those who worked in them. in 1980. Community-Based Care The future of psychiatric care and psychiatric nursing will be linked to efforts to prevent mental health problems and treat existing disorders more effectively. Inc. Living arrangements include community shelters. much of that effort will be community based as part of a continuum of care.000 are homeless each night. many from both. public mental hospitals lost prestige. General hospital psychiatric units are overwhelmed. are psychotic and are typically acutely ill young men. Public awareness of mental disorders grew. who have been displaced by social policies over which they have no control.Instructor's Manual Community Effects Benchmark V: Decade of the Brain 1-4 own. Issues That Affect the Delivery of Psychiatric Care Paradigm Shift in As interest in psychotherapy and disinterest in severely Psychiatric Care mentally ill patients grew during the 1930s and 1940s. During the 1990s. rehabilitation programs. cheap hotels. Emergency department use is increased. an affiliate of Elsevier Inc. including families with children and individuals employed in low-paying jobs. publication of the DSM-III returned the focus to individuals with psychiatric disorders. The Diagnostic and Statistical Manual of Mental Disorders was revised. Homelessness This problem is linked to deinstitutionalization. However. Nursing textbooks began to provide more detailed information about psychobiology and psychopharmacology. As many as 50% to 75% of the homeless suffer from alcohol or drug abuse. Hospitalized patients require a high level of care. allowing SMI patients to go untreated  Restrictive confidentiality rulings to meet needs of SMI Develop a seamless continuum of care to: Copyright © 2007 by Mosby. All rights reserved. Developing a Continuum of Factors leading to unmet needs of SMI: Care  Liberalization of commitment laws. an increase in brain research studies coincided with increased interest in biologic explanations for mental disorders. prisons. halfway houses. About 800. board-and-care homes. Today’s patients are seen to be more aggressive. Psychiatry changed focus from the severely mentally ill to the worried well.. and jails. have few social relationships. Based on economic reality. .

 facilitate movement between and among continuum entities. All rights reserved. and evaluating mental health services and community services. emphasized the interpersonal dimension of practice Copyright © 2007 by Mosby. and supports The current manual. directed a school of psychiatric nursing ~1880 Written by Harriet Bailey in 1920 1937: NLN recommended that psychiatric nursing become part of general nursing curriculum Hildegarde Peplau: developed model for psychiatric nursing. and tertiary prevention of mental illness Nursing values that fit with concept of a care continuum:  Holistic view of patient  Working with families  Treating patients in own home  Developing relationships over time  Educating patients  Assessing environment for safety. These include promotion of continuum of primary. finances) rather than on medication management.Instructor's Manual Role for Nursing in the Continuum of Care The Diagnostic “Bible” of Psychiatry Psychiatric Nursing Education: Three Firsts First Psychiatric Nurse First Psychiatric Nursing Textbook First Psychiatric Nursing Theorist 1-5  coordinate activities of diverse treatment sources. wrote Interpersonal Relations in Nursing in 1952. secondary. planning.. less on symptom stabilization  Involve consumers and family members more  Focus on holistic thinking (stabilizing housing. CMH role defined in 1982 by ANA: nurse participates with other members of community in assessing. DSM-IV-TR provides five axes to use in patient assessment:  Axis I: clinical disorders  Axis II: personality or developmental disorders  Axis III: general medical conditions that relate to axes 1 and II or have a bearing on treatment  Axis IV: severity of psychosocial stressors  Axis V: global assessment of functioning (scale of 0 to 100) Linda Richards: first American psychiatric nurse. implementing. hygiene. medical health. active in developing nursing care in psychiatric hospitals. an affiliate of Elsevier Inc. Inc. Develop a new conceptualization of system:  Focus more on recovery and reintegration. .