Psychiatric Nursing

### Definition of Psychiatric Nursing

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Psychiatric mental health (PMH) nursing is an area of focus within nursing. Psychiatric mental health registered nurses work with individuals, families, groups, and communities, assessing their mental health needs. The PMH nurse develops a nursing diagnosis and plan of care, implements the nursing process, and evaluates it for effectiveness. Psychiatric Mental Health Advanced Practice Registered Nurses (PMH-APRNs) offer primary care services to the psychiatric-mental health population. PMH-APRNs assess, diagnose, and treat individuals and families with psychiatric disorders or the potential for such disorders using their full scope of therapeutic skills, including the prescription of medication and administration of psychotherapy. PMH-APRNs often own private practices and corporations as well as consult with groups, communities, legislators, and corporations.[1]

### Treatment Settings

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* Primary Care Providers
* Psychiatric Care Providers
* Community Mental Health Centers
* Psychiatric Home Care
* Intense Outpatient Venues
* Emergency Inpatient Care[2]

### Legal and Ethical Considerations

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Patients' Rights Under The Law

Right to Treatment  | Right to be free from excessive or unnecessary medication

Right to privacy and dignity.

Right to the least restrictive environment.

Right to an attorney, clergy, and private care providers.

The right to not be subjected to invasive medical treatment without informed consent. [2]

Right to Refuse Treatment  | [2][2][2]Unless

1. The person has a serious mental illness.
2. The person's ability to function is deteriorating or he or she is exhibiting threatening behavior.
3. The benifits of treatment outweigh the harm.
4. The person lacks the ability to make a reasoned decision regarding their treatment.
5. Less restrictive services have been found inappropriate.

Right to Informed Consent  | The patient must be informed of the following elements:

* Nature of the probelm or condition
* Nature or purpose of the treatment
* The risk and benefits of the treatment
* The purpose of the proposed treatment
* Alternative treatment options.
* The probability that the treatment will be successful.
* The risk of not consenting to the treatment. [2]

Rights Regarding Psychiatric Advanced Directives  | For patients who have experienced an episode of severe mental illness. This allows for the opportunity to express their treatment preferences in detail and include:

* Preferred physicians and therapists
* Designation of someone to make mental health treatment decisions
* Preferences in medications they wish to take or not take
* Consent or lack of consent for admission to a psychiatric facility.
* Preferred facilities for treatment as well as unacceptable facilities.
* Identifying individuals they would like to allow visit during treatment. [2]

Rights regarding Restraint and Seclusion  | The American Psychiatric Nurses Association (APNA) promotes a culture of minimizing and eventually eliminating the need for the use of seclusion and restraint. [3]

Nurses should consider the following interventions before using seclusion and restraint.

* Verbally intervening (asking the patient for cooperation)
* Reducing stimulation
* Actively listening to the client
* Providing diversion or distraction to the client
* Offering a PRN medication if ordered [2]

Right to Privacy  | Confidentiality is the ethical responsibility of healthcare professionals that prohibit the disclosure of privileged information without the consent of the client.

The Health Insurance Portability and Accountability Act (HIPAA) legally protects psychiatric patient's right to receive treatment and to have their medical records kept confidential.

Exceptions to the rule

Duty to warn and protect third parties. Health professionals must inform a patient's potential victim of harm if the provider believes they are in danger.

Duty to report suspected child and elder abuse. If a healthcare provider suspects physical abuse, sexual abuse, financial abuse, or neglect they must report the suspicion to the proper authorities. [2]

### Therapeutic Relationships

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The nurse maximizes communication skills, understand of human behaviors and personal strengths to enhance the patient growth.

Goals for Therapeutic Communication.  The Nurse will...

* Identify client needs and explore them.
* Establish clear boundaries.
* Encourage alternate problem solving.
* Help the patient develop new coping skills.
* Support behavioral change.[2]

The Communication Process

Stimulus | Starts with one person who has a need to communicate with another for information, comfort or advice.
Sender | The person sending the message initiates interpersonal contact.

Message filters through personal factors

* Personal agenda/goals
* Personal bias
* Personal relationship
* Culture
* Past experience
* Mood/attitude
* Value system
* Knowledge
* Ability to relate to other people
* Environmental factors
* Gender roles[4]

Message | The message is the information sent or expressed to another person.

Can Be

Verbal

Nonverbal

* Visual (body language
* Tactile
* Olfactory (body odor)
* Silence

Both Verbal and Nonverbal

* May substantiate
* May contradict

Receiver | The person receiving the message then interprets the message and responds to the sender by providing feedback.

Message filters through personal factors

* Personal agenda/goals
* Personal bias
* Personal relationship
* Culture
* Past experience
* Mood/attitude
* Value system
* Knowledge
* Ability to relate to other people
* Environmental factors
* Gender roles[4]

Peplau's Model of the Nurse-Patient Relationship[2]

Preorientation Phase | Starts while the nurse is preparing for their assignment and the nurse reviews the client progress notes and data.
Orientation Phase | Can last for the first few meetings with patient, but starts during the introduction to patient.

* Establish rapport
* Specify the contract
* Explain confidentiality

Working Phase | During this phase the nurse and the client work on recognizing problems in the patient's life.

* Gather data.
* Identify problem-solving skills and self esteem.
* Provide patient education about the disorder.
* Promote symptom management.
* Provide medications to clients and education about the medications.
* Evaluate the client's progress.

Termination Phase | The final phase of the nursing patient relationship. This can occur when a patient is being discharged or at the end of a shift.

* Summarize the goals and objectives achieved during the relationship.
* Discuss ways for patients to incorporate learned skills into daily life.
* Exchange memories, which can help validate the experiences for both the nurse and patient and facilitate closure.

### Certifications (RN-BC)

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Certifications for psychiatric nurses is known the RN-BC. This is provided through the American Nurses Credentialing Center (ANCC). The ANCC requires for the psychiatric mental health nurse have two years of experience as a full time registered nurse with 2,000 hours of minimum clinical practice before taking the examination. The nurse must complete 30 hours of continuing education within 3 years to renew the certification.[1]

### Advanced Practice Registered Nurses (APRN)

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Advanced practice registered nurses (APRN) earn master’s or doctoral degrees in psychiatric-mental health nursing. APRNs apply the nursing process to assess, diagnose, and treat individuals or families with psychiatric disorders and identify risk factors for such disorders. They also contribute to policy development, quality improvement, practice evaluation, and healthcare reform. The practice of the psychiatric-mental health nurse (PMHN) as a Clinical Nurse Specialist or Nurse Practitioner is considered an advanced specialty in nursing. APRNs practice as Clinical Nurse Specialists (CNSs) or Nurse Practitioners (NPs). The doctoral degree for the advanced clinical practice of psychiatric nursing is the Doctor of Nursing Practice (DNP). APRNs also earn additional degrees (PhD and EdD) which prepare them to work as professors, researchers, or administrators. PMH-APRN practice authority varies by state.[1]

### Goals of Psychiatric Nursing Care

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* Develop nursing diagnosis
* Develop plan of care
* implement the nursing process
* evaluate the plan for effectiveness

1. ↑ 1.0 1.1 1.2 "Psychiatric-Mental Health Nurses - www.apna.org". www.apna.org. Retrieved 2020-08-10.
2. ↑ 2.00 2.01 2.02 2.03 2.04 2.05 2.06 2.07 2.08 2.09 2.10 Halter, Margaret J. (Margaret Jordan). Varcarolis' foundations of psychiatric-mental health nursing : a clinical approach (8 ed.). St. Louis, Missouri. ISBN 978-0-323-38967-9. OCLC 981508782. https://www.worldcat.org/oclc/981508782.
3. ↑ "Use of Seclusion and Restraint - www.apna.org". www.apna.org. Retrieved 2020-08-11.
4. ↑ 4.0 4.1 "COMMUNICATION IN NURSING". faculty.valenciacollege.edu. Retrieved 2020-08-11.