CHAPTER 1: Foundations of Psychiatric-Mental Health Nursing

Chapter 1: Foundations of Psychiatric-Mental Health Nursing:

**MAKE SURE TO REFERENCE POWERPOINTS, END OF CHAPTER KEY POINTS, PLQ, END OF
CHAPTER REVIEWS, THE POINT QUESTIONS AND PREP U**

Key Terms:
o Asylum: a safe refuge or haven offering protection; in the U.S, the term asylum was used to describe
institutions for the mentally ill
o Boarding: patients kept in the ED while waiting to see if the crisis de-escalates or till an inpatient bed can
be located or becomes available; patients coming to a general ED are immediately transferred to a
designated emergency psychiatric facility as soon as they are medically stable
o Case Management: management of care on a case-by-case basis, representing an effort to provide
necessary services while containing cost; in the community, case management services include accessing
medical and psychiatric services and providing assistance with tasks of daily living such as financial
management, transportation, and buying groceries
o Deinstitutionalization: a deliberate shift in care of the mentally ill from institutional care in state hospitals
to care in community-based facilities and though community-based services
o Diagnostic and Statistical Manual of Mental Disorders (DSM-5): taxonomy published by the APA; the
DSM-5 describes all mental disorders ad outlines specific diagnostic criteria for each based on clinical
experience and research
o Managed Care: a concept designed to purposely control the balance between the quality of care provided
and the cost of that care
o Managed Care Organizations: developed to control the expenditure of insurance funds by requiring
providers to seek approval before the delivery of care
o Mental Health: a state of emotional, psychological, and social wellness evidenced by satisfying
relationships, effective behavior and coping, positive self-concept, and emotional stability
o Mental Illness: a clinically significant behavioral or psychological syndrome or pattern that occurs in an
individual and that is associated with present distress (ex: a painful symptom) or disability (ex:
impairment in one or more important areas of functioning) or with a significantly increased risk of
suffering death, pain, disability, or an important loss of freedom
o Phenomena of Concern: describe the 12 areas of concern that mental health nurses focus on when caring
for clients
o Psychotropic Drugs: drugs that affect mood, behavior, and thinking that are used to treat mental illness
o Self-awareness: the process by which a person gains recognition of his or her own feelings, beliefs, and
attitudes; the process f developing an understanding of ones own values, beliefs, thoughts, feelings,
attitudes, motivations, prejudices, strengths, and limitations and how these qualities affect others
o Standards of Care: authoritative statements by professional organizations that describe the responsibilities
for which nurses are accountable; the care that nurses provide to clients meets set expectations and is
what any nurse in a similar situation would do
o Utilization Review Firms: develop to control the expenditure of insurance funds by requiring providers to
seek approval before the delivery of care
Learning Objectives:
o Describe characteristics of mental health and mental illness.
Mental Health:
WHO defines mental health as a state of complete physical, mental, and social wellness,
not merely the absence of disease or infirmary
No single universal definition exists
Has many components and wide variety of factors influencing it
A persons mental health is a dynamic or ever-changing state
Factors can be categorized as individual, interpersonal, and social/cultural
Mental Illness:
Includes disorders that affect mood, behavior, and thinking, such as depression,
schizophrenia, anxiety disorders, and addictive disorders
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CHAPTER 1: Foundations of Psychiatric-Mental Health Nursing
Factors contributing to mental illness can also be viewed within individual, interpersonal,
and social/cultural categories
o Discuss the purpose and use of the American Psychiatric Associations Diagnostic and Statistical Manual
of Mental Disorders (DSM-5).
A taxonomy published by the American Psychiatric Association and is revised as needed
Describes all mental disorders, outlining specific diagnostic criteria for each based on clinical
experience and research
Has 3 purposes:
To provide a standardized nomenclature and language for all mental health professionals
To present defining characteristics or symptoms that differentiate specific diagnoses
To assist in identifying the underlying causes of disorders
Classification system allows practitioners too identify all factors that relate to a persons
condition:
All major psych disorders such as depression, schizophrenia, anxiety, and substance
related disorders
Medical conditions that may be potentially relevant to understanding or managing a
persons mental disorder as well as medical conditions that might contribute to
understanding the person
Psychosocial and environmental problems that may affect diagnosis, treatment, and
prognosis of mental disorders
Student nurses dont use DSM-5 to diagnoses, just a resource to understand why patients are
admitted, and to understand psychiatric illness
o Identify important historical landmarks in psychiatric care.
Ancient Times:
People in the ancient times believed that any sickness indicated displeasure of the gods
and was a punishment for sins and wrong doings
Those with mental illnesses were viewed as being either divine (worshiped or adored) or
demonic (were ostracized, punished, and sometimes burned), depending on behavior
Aristotle (382-322 BC): attempted to relate mental health disorders to physical disorders
and developed his theory that the amounts of four humor imbalances (blood, water, and
yellow and black bile) in the body controlled the emotions; treatment was restoring
balance through bloodletting, starving, and purging
Christian times (1-100 AD): all diseases were again blamed on demons, and the mentally
ill were viewed as possessed; priests performed exorcisms to rid evil spirits, more brutal
measures were taken when exorcisms failed
England during Renaissance (1300-1600): people with mental illness were distinguished
from criminals; those who were considered dangerous lunatics were thrown in prison,
chained, and starved
1547: Hospital of St. Mary of Bethlehem was officially declared a hospital for the insane,
first of its kind
Period of Enlightenment and Creation of Mental Institutions:
Phillippe Pinel (France) and William Tuke (England) (1790s): formulated the concept of
asylum as a safe refuge or haven offering protection at institutions where people just been
whipped, beaten, and starved just for being mentally ill
Dorothea Dix (U.S, 1802-1887): began a crusade to reform the treatment of mental
illness after a visit to Tukes institution in England; believe that society was obligated to
those who were mentally ill; she advocated adequate shelter, nutritious food, and warm
clothing
Sigmund Freud and Treatment of Mental Disorders:
Sigmund Freud (1856-1939), Emil Kraepelin (1856-1926), Eugen Bleuler (1857-1939):
period of scientific study and treatment of mental disorders began
o Freud: challenged society to view human beings objectively; studied the mind, its
disorders, and their treatment as no one had done before

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CHAPTER 1: Foundations of Psychiatric-Mental Health Nursing
o Kraepelin: began classifying mental disorders according to their symptoms
o Bleuler: coined the term schizophrenia
Development of Psychopharmacology:
1950s and development of psychotropic drugs
Chlorpromazine (Thorazine) antipsychotic drug and Lithium anti-manic agent first drugs
developed
10 years following: monoamine oxidase inhibitor antidepressants; haloperidol (Haldol)
antipsychotic; tricyclic antidepressants; and benzodiazepines antianxiety agents were
introduced
Move toward Community Mental Health:
Community Mental Health Centers Constitution Act: enacted in 1963, was the movement
toward treating those with mental illness in less restrictive environments
Deinstitutionalization a deliberate shift from institutional care in state hospitals to
community facilities began; accomplished the release of individuals from long-term stays
in state institutions, the decrease in admissions to hospitals, and the development of
community based services as an alternative to hospital care
Federal legislation was passed to provide an income for disabled persons: Supplemental
Security Income (SSI) and Social Security Disability Income (SSDI), allowing people
with severe and persistent mental illness to be more independent financially and to not
rely on family for money
Commitment laws changed in early 1970s making it more difficult to commit people for
mental health treatment against their will
o Discuss current trends in the treatment of people with mental illness.
Economic burden exceeds all types of cancer.
More than 10 million children younger than 7 grow up in homes when at least one parent suffers
from significant mental illness or substance abuse, a situation that hinders the readiness of these
children to start school
Mental disorders are the leading cause of disability in the U.S and Canada for persons 15-44
years of age
1 in 4 adults, and 1 in 5 children and adolescents requiring mental health services get the care
needed
Those with severe and persistent mental illness may show signs of improvement in a few days but
are nor stabilized
Many have a duel problem of both severe alcohol and drugs which exacerbates symptoms of
mental illness, making re-hospitalization more likely
Substance abuse issues cant be dealt with in the typical 3-5 day hospital stay in current managed
care environments
Homelessness is a major problem in the U.S, 610,00 people including 140,000 children, approx.
257,300 (42%) of homeless population have a severe mental illness or a chronic substance
disorder
Those mentally ill and homeless are typically found in parks, airports and bus terminals,
alleys, stairwells, jails and other public places
Some may use halfway houses, shelters, or board-and-care rooms
Others rent cheap hotels
Worsens psychiatric problems for many people with mental illness who end up on streets,
contributing to vicious cycles
Healthy People 2020 Mental Health Objectives Box 1.1 Pg. 5
Community support service programs were developed to meet the needs of persons with mental
illness outside the walls of an institution
Cost Containment and Managed Care:
Managed care is a concept designed to purposely control the balance between the quality
of care provided and the cost of that care, people receive care based on need rather than
request, began in the early 1970s

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CHAPTER 1: Foundations of Psychiatric-Mental Health Nursing
In 1990s a new form of managed care was opened by utilization review firms or
managed care organizations to control the expenditure of insurance funds by requiring
providers to seek approval before the delivery of care, which represents an effort to
contain costs
Psychiatric care is costly because of the long-term nature of disorders, can cost 20,000-
30,00 for a single hospital stay
Mental health care in terms of insurance coverage is separate from physical health care
Managed care is managed through privately owned behavioral health-care firms that
often provide the services and managed their cost those without private insurance must
rely on counties of residence for tax dollar funding
The Health Care Finance Administration administers two insurance programs: Medicare
and Medicaid:
o Medicare: covers 65 years and older, permanent kidney failure, and certain
disabilities
o Medicaid: jointly funded by the federal and state governments and covers low-
income individuals and families; varies by state; covers those receiving SSI
(eligible immediately) and SSDI (not eligible for 24 months) until 65 years of
age
1996 Congress pass the Mental Health Parity Act eliminating annual and life time dollar
amounts for mental health care for companies with more than 50 employees, substance
abuse wasnt covered by this law, and companies could still limit the number of days
spent in hospital or clinic each year
o Discuss the American Nurses Association (ANA) standards of practice for psychiatric-mental health
nursing.
Linda Richards: graduated NE Hospital for Women and Children in Boston (1873); improved
nursing care in psychiatric hospitals and organized educational programs in state mental hospitals
in Illinois; called the first American psychiatric nurse; believed the mentally sick should be at
least as well cared for as the physically sick
McLean Hospital: in Belmont, MA; first place to train nurses to work with mentally ill (1882);
treatments included insulin shock therapy (1935), psychosurgery (1936), and electroconvulsive
therapy (1937) requiring nurses to use medical surgical skills more intensely
Harriet Bailey: first psychiatric text book author Nursing Mental Diseases published 1920
John Hopkins: first school of nursing to include psychiatric course
1950 National League for Nursing required all schools to experience psychiatric nursing
Hildegard Peplau and June Mellow: nursing theorist shaping psychiatric nursing practice
Peplau: published Interpersonal Relations in Nursing (1952) and Interpersonal
Techniques: The Crux of Psychiatric Nursing (1962); described therapeutic nurse-client
relationship with its phases and tasks; wrote about anxiety
Mellow: wrote Nursing Therapy (1968), described her approach of focusing on client
psychosocial needs and strength; contended that the nurse as therapist is particularly
suited to working with those with severe mental illness in the context of daily activities
(1986)
ANA: develops standards of care, revised when needed; authorize statements by professional
organizations that describe the responsibilities for which nurses are accountable; not legally
binding unless they are incorporated into the state nurse act or state board rules and regulations
American Psychiatric Nurses Association (APNA): has standards of practice and standards of
professional performance; also outlines the areas of practice and phenomena of concern for
todays psychiatric-mental health nurse
Psychiatric-Mental Health Nursing Phenomena of Concern Box 1.2 Pg. 8
Areas of Practice Box 1.3 Pg. 8
o Describe common student concerns about psychiatric nursing.
Fear of saying the wrong thing
Curiosity of what clinical will consist of
Worry of patients not speaking to them
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CHAPTER 1: Foundations of Psychiatric-Mental Health Nursing
Concerned if they are prying when asking personal questions
Concerned how they will handle bizarre or inappropriate behavior, if a client asks them on a date
or displays aggressive or sexual behavior
Wondering if their own physical safety is in jeopardy
Concerned if they know someone on the unit
Recognizing that they share similar issues and backgrounds with the patients being treated

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