Download Weekly Course Learning Activities and more Lecture notes Nursing in PDF only on Docsity!
Week 1: Req Readings: Boland, R., & Verduin, M. L. (2022). Kaplan and Sadock's synopsis of psychiatry (12th ed.). Wolters Kluwer.
- Ch. 25: Consultation-Liaison Psychiatry
- Ch. 26: Level of Care
- Ch. 27: Ethics and Professionalism
- Ch. 28: High-Risk Clinical Situations-hospitalization Mental illnesses vary in severity, ranging from mild to moderate to severe (National Institute of Mental Health [NIMH], 2022). According to the NIMH (2022), serious mental illness is a disabling mental disorder that significantly impairs life activities and reduces life expectancy. In 2020, serious mental illness impacted an estimated 14.2 million adults aged 18 or older in the United States; rates were higher among females, young adults aged 18-25 years, and minority populations. Mental illness can also be complex. Individuals with complex mental health may also have a substance use disorder or dual diagnosis or significant co-occurring physical and mental health needs. Serious mental illness and complex mental health disorders are often associated with significant challenges in diagnosis, treatment, and recovery. Legal and ethical dilemmas may also arise when providing care for these clients. As a key member of the primary care team, the psychiatric mental health nurse practitioner (PMHNP) offers essential services that are crucial to the comprehensive treatment of these individuals. Role Description and Rationale Primary Care The PMHNP (Psychiatric Mental Health Nurse Practitioner) is providing care to a 29-year-old client who presents with persistent sadness and hopelessness for the last two months. She is having difficulty sleeping and has a decreased appetite. This is the patient's first contact with with the healthcare system about her concerns [Rationale: This is the client's initial contact with the healthcare system about her concerns]. Pharmacologic Intervention The client has experienced depressive symptoms. The PMHNP prescribes a selective serotonin reuptake inhibitor (SSRI). [Rationale: The PMHNP is prescribing psychopharmacotherapy for the client]. Psychotherapy The PMHNP provides the client with some mindfulness techniques to try at home [Rationale: The PMHNP is utilizing a psychotherapeutic approach to help the client gain insight]. Crisis Intervention Two weeks after starting on the SSRI, the client begins to experience suicidal ideations and develops a plan to kill herself. A friend brings the client to the emergency room. The PMHNP meets the client at the
emergency room and collaborates with the physician to coordinate care [Rationale: Suicidal ideation with a plan is a psychiatric emergency requiring immediate intervention]. Acute PMHNP Care The client is admitted to the psychiatric and behavioral health unit at the local hospital for a 72-hour observation where the PMHNP works with her team providing treatment. The client remains hospitalized for a week while her medications are managed. The client attends individual and group therapy sessions [Rationale: Acute iPMHNPatient care occurs in an intensive hospital or psychiatric facility setting]. Partial Hospitalization/Intensive Outpatient Treatment Following hospitalization, the client returns home but commutes to a treatment center for 4 hours a day 5 days per week for ongoing therapy, medication management, and psychoeducation [Rationale: Partial Hospitalization/Intensive Outpatient Treatment occurs when a client receives intensive therapy on an outpatient basis, often used when a client do not require 24-hour care but still require intense treatment]. Case Management The PMHNP serves as the point of contact person, coordinating the treatment team, which consists of the PMHNP, a social worker, and possibly a psychologist and psychiatrist [Rationale: Case management involves oversight and/or coordination of care]. Community-Based Care Over the course of 2 months, the client's condition improves. She is discharged from intensive outpatient treatment and begins weekly appointments with the PMHNP at the PMHNP's clinic [Rationale: Community-based care is provided in a non-hospital community setting]. Telehealth A global pandemic limits face-to-face mental health visits, the PMHNP determines that the patient requires ongoing mental health treatment. The PMHNP arranges to meet with the client via weekly interactive video sessions [Rationale: Telehealth services utilize telecommunication technology to deliver treatment to clients]. Self-Employment The PMHNP owns the private practice that is providing services to the client [Rationale: The PMHNP is providing direct services through her own private practice]. Code of Ethics Respect for the Individual The PMHNP
- approaches professional relationships with compassion, caring, and respect, acknowledging the dignity and worth of each individual.
- helps instill hope and empowers those with PMH disorders.
- affirms the worth and dignity of those with PMH disorders by advocating to overcome negative stigmas towards PMH diagnoses to ensure access to care.
Duties to Self and Others The PMHNP
- owes the same duties to self as to others.
- accords moral worth and dignity to oneself and others, including colleagues.
- is committed to practicing self-care, managing stress, and maintaining supportive relationships to meet personal needs outside of therapeutic relationships.
- identifies and addresses moral distress. Contributions to Healthcare Environments The PMHNP
- helps maintain and improve healthcare environments and conditions of employment.
- recognizes signs and symptoms of psychiatric disorders in the workplace and reports peer observations or concerns to leadership.
- helps address problems faced by colleagues that may impact patient safety or violate public trust, including substance abuse. Advancement of the Nursing Profession The PMHNP
- contributes to advancing the professing through practice, education, administration, and knowledge development.
- maintains knowledge of and apply evidence-based practice guidelines, including risk assessment and management.
- participates in continuous quality improvement.
- pursues continuing education. Collaboration to Meet Health Needs The PMHNP
- promotes community, national, and international efforts to meet health needs through collaboration with other healthcare professionals.
- engages in partnerships with other specialty nurses, government agencies, professional nursing organizations, and mental health organizations to promote prevention, treatment, and recovery.
Promotion of the Nursing Profession The PMHNP
- advocates for environments that respect human rights, customs, and spiritual beliefs of individuals, families, and communities.
- engages in interactions and collaborations to articulate nursing values and maintain the integrity of the profession.
- participates in policy development and implementation that recognizes PMH disorders as treatable and ensures that nursing care is delivered with respect to human needs and values without prejudice. Applying Ethical Principles Respect for the Individual: Scenario Person A: "I can't believe you deal with these people every day. Schizophrenics would drive ME crazy!" PMHNP: "Actually, schizophrenia is a chronic treatable disease, much like diabetes or other physical illnesses. Patients who have mental illness deserve compassion and care." Rationale Respect for the individual affirms the worth and dignity of those with PMH disorders by advocating to overcome negative stigmas towards PMH diagnoses to ensure access to care. Commitment to the Healthcare Consumer: Scenario The client presents to the emergency department with hallucinations and is threatening self-harm. The PMHNP signs an involuntary admission order for emergent psychiatric care. Rationale The PMHNP demonstrates a commitment to the healthcare consumer by balancing the client's human rights with safety, including coercive measures when the client was unable to maintain their own safety.
Contributions to Healthcare Environments: Scenario A PMHNP discovers her colleague is diverting scheduled medications to self-medicate anxiety. The PMHNP reports the concerns to the colleagues supervisor. Rationale The PMHNP recognizes signs/symptoms of psychiatric disorders in the workplace reporting peer observations to leadership. The PMHNP helps address problems faced by colleagues that impact client safety or violate public trust, including substance abuse. Advancement of the Nursing Profession: Scenario The PMHNP gives a presentation at a national conference on best practices in depression treatment. Rationale The PMHNP contributes to advancing the professing through practice, education, administration, and knowledge development. Collaboration to meet health needs: Scenario The PMHNP is a member of the American Nurses Association (ANA) and National Alliance on Mental Illness (NAMI) and regularly participates in workgroups that seek to expand access to care for healthcare consumers with PMH disorders. Rationale The PMHNP promotes community, national, and international efforts to meet health needs through collaboration with other healthcare professionals to promote prevention, treatment, and recovery.
Promotion of the Nursing Profession: Scenario A PMHNP speaks at a school board meeting about the need develop policies to expand mental health services for underserved students. Rationale The PMHNP participates in policy development and implementation that recognizes PMH disorders as treatable and ensures that nursing care is delivered with respect to human needs and values without prejudice. Steps that are required to obtain informed consent, according to the American Medical Association:
- Assess client ability to understand medical information and treatment options and to make a voluntary decision.
- Present relevant information with accuracy and sensitivity. Should include information about: o diagnosis o nature and purpose of treatment options o benefits, risks, and burdens of all treatment options, including forgoing treatment
- Document informed consent conversation in the medical record, including all consent forms. The Role of the Psychiatric Mental Health Nurse Practitioner in Managing Clients with Complex Disorders Background The troubling state of mental health in the United States has erupted into a national mental health crisis. The evolving COVID-19 pandemic and associated disruptions in work, school, and public life, along with compounding stressors of rising inflation, political conflict, structural racism, climate change, and military conflict in the world, have led to a staggering rise in mental health disorders, especially among children and adolescents and underserved populations (American Psychological Association [APA], 2022). Mental health disorders are now among the top disabling health problems and represent a high proportion of healthcare visits (American Psychiatric Nurses Association [APNA], 2020). Compounding stressors and an ongoing public health emergency have led to more challenging conditions (Kumar & Nayar, 2021). Individuals with serious mental illness often have significant physical and mental health needs and comorbidities. Management of these clients is also complex: symptom burden is often heavy due to overlapping symptoms, diagnosis may be challenging, and many disorders are difficult to treat. Lack of access to resources and provider shortages can make a recovery from complex disorders very challenging. Psychiatric mental health nurse practitioners (PMHNPs) are integral in any disaster and urgently important in this mental health emergency. The pandemic is unique in its influence on millions of individuals and is anticipated to have a lasting, traumatic impact on generations (APA, 2022). Access to evidence-based treatments and mitigating risk is critical, as is mental health prevention. The PMHNP is critical to meeting our nation's emergent and increasingly complex mental health care needs.
Rebecca: I enjoy the autonomy that I have in my state. I’ve been working at the university hospital here in town. There is something new every day. Most days, I work in the adolescent acute inpatient unit, but sometimes I’m called to the emergency department for a consultation. I see about 15 clients a day on the unit. The average length of stay is about 5-7 days. I love having the opportunity to work towards stabilization with clients, but I'm sometimes frustrated because there often seems to be a lack of outpatient resources available, especially for clients with limited insurance coverage. Kristin: I know just what you mean. I work in a community mental health clinic, and we have a waiting list for appointments. Most of our new clients must wait over a month for their first appointment. That said, I really like my work. I work mostly with adults. Some of my appointments are brief: just 15 minutes for medication checks, which involves reviewing lab work, a brief interview, and a refill prescription, but I also have clients who come for counseling- mostly cognitive behavioral therapy. I enjoy building relationships with them week after week. I also love my Monday to Friday 8-4: schedule, and we have a great team that includes a psychiatrist, three social workers, and another nurse practitioner. Rebecca: Wow! That sounds fantastic! I work four ten-hour shifts a week and take overnight calls several times a month. Kristin: Yeah. I am considering working at the women's prison a few days a month to expand my practice a bit. Adam: That sounds fascinating. You will have to keep us updated. I think it is amazing that we all practice in such different settings but still find meaning in our work. I know it isn’t always easy, but it sounds like we are on the right track. Rebecca: For sure! I missed talking to you guys. Let’s make sure we set a time so we can get together regularly and talk about what’s happening! Adam and Kristin: Sure! Wow! Yeah! Bye!
Legal and Ethical Implications in the Treatment of Clients with Complex Disorders Background Legal and ethical dilemmas may arise when providing care for clients with complex diagnoses. At times, mental illness can impair a client’s capacity to make informed decisions for themselves. The side effects of some mental health treatments may lead clients to choose nonadherence to treatment recommendations. A client's psychiatric symptoms may compromise their safety or the safety of others. Unfortunately, there is a sad history of abuse and exploitation of clients with mental illness (Morris, 2020). In the past, clients were often subjected to dangerous or uncomfortable experimental treatments to control psychiatric symptoms. Involuntary commitment without time limits, restraints, and seclusion were common practices and were often applied punitively in hospitals and facilities throughout the United States; however, over time, such practices have been challenged as violations of clients’ rights, and some mental health reform has occurred. Ethical and legal considerations are now an integral part of treatment decisions. However, ethical dilemmas may arise when clients’ wishes differ from treatment recommendations or when interprofessional team members disagree about the best course of action in the treatment of a client. Mental Health Amercia’s 2015 position statement stipulates that professionals must respect the client’s fundamental rights of the client for dignity, autonomy, and self-determination while addressing concerns about the safety and well-being of the client and others. 6 key core skills that are critical to ethical decision-making in mental health care:
- Ability to identify ethical issues
- Ability to understand how one’s values, beliefs, and sense of self, including implicit biases, impact client care
- Ability to recognize personal limits to knowledge and expertise and willingness to practice within limits
- Ability to recognize situations that present a high risk for ethical dilemmas
- Willingness to seek information and consultation in difficult ethical or clinical situations
- Ability to build ethical safeguards into one’s practice
Unrepresented clients are clients without advance directives and available family or friends to make decisions. State laws and institutional policies typically take one of three approaches in choosing a decision-maker: the physician or provider, an ethics committee, or a court-appointed guardian (Blackstone, et al., 2020). Discover More Learn more about using a formal assessment tool to assist in determining capacity: Aid To Capacity Evaluation (ACE) Learn by Applying Yolanda Yolanda is a 20-year-old client who was referred to the PMHNP by her college health clinic for symptoms consistent with bipolar II disorder. She initiates the interview by stating that she is not willing to take any medications but is willing to engage in counseling or other therapies. Which of the following is the most appropriate action?
- provide additional education (Correct answer)
- document refusal of treatment
- initiate treatment without informed consent Rationale: The client should receive education about the risks, benefits, and appropriateness of pharmacological treatment. If, after receiving education, the client still refuses medication therapy, it is important to document the education provided and the client’s refusal of treatment. Kevin Kevin is a 48-year-old with a 20-year history of schizophrenia. He has decided to stop pharmacological treatment due to the intolerable adverse effects of his medications. Kevin and the provider have discussed the benefits and drawbacks of ceasing treatment, and he has agreed to weekly telephone check-ins to ensure his well-being. Which of the following is the most appropriate action?
- provide additional education
- document refusal of treatment (Correct answer)
- initiate treatment without informed consent Rationale: The client has the capacity to consent, and the situation is not emergent. The ethic of autonomy provides for the client to refuse treatment.
Ashlei Ashlei is a 19-year-old who presents to the clinic with severe anxiety symptoms. As the PMHNP begins reviewing treatment options, Ashlei interrupts and states, “Hearing about these medications increases my anxiety. Please prescribe what you think is best for me, and I will take it.” Which of the following is the most appropriate action?
- provide additional education
- document refusal of treatment
- initiate treatment without informed consent (Correct answer) Rationale: Clients may choose to waive their right to informed consent. The PMHNP should clearly document the client’s waiver. Geoff Geoff is a 32-year-old who presents to the clinic with anhedonia, fatigue, feelings of worthlessness, and a lack of focus. He admits to thinking about death but denies suicidal ideations or a plan. He has been taking sertraline 50 mg daily and wishes to stop taking the medication as it does not seem to be helping. Which of the following is the most appropriate action?
- provide additional education (Correct answer)
- document refusal of treatment
- initiate treatment without informed consent Rationale: The client has the capacity to provide consent and the situation is not emergent; however, the client should receive education about the risks, benefits, and appropriateness of pharmacological treatment. At this time, the dose should be increased to achieve efficacy. If, after receiving education, the client still refuses medication therapy, the PMHNP should document the education provided and the client’s refusal of treatment. Fritz Fritz is a 25-year-old who has been brought to the emergency department by the police after threatening a server at a restaurant. The PMHNP on call has treated Fritz for schizophrenia in the past. He has a history of poor treatment adherence. While in the emergency department, he admits to auditory hallucinations. He becomes agitated and begins throwing items around the examination room. Which of the following is the most appropriate action?
- provide additional education
- document refusal of treatment
- initiate treatment without informed consent (Correct answer)
Discover More Learn more about state criteria for involuntary inpatient and involuntary outpatient commitment for care: https://mentalillnesspolicy.org/national-studies/state-standards-involuntary-treatment.html Learn by Applying Keith Keith is a 35-year-old who presents to the crisis clinic with his wife, who is very concerned about Keith’s recent behavior. He believes his neighbors have been spying on him using technology acquired from a secret government source. He is agitated and states, “I just have to take them out. I can’t have them looking at us anymore. I’m going to have to build a blaster to take them out.” Keith’s wife confirms that there are no weapons in the home. Keith is willing to initiate treatment but does not want to be admitted as an inpatient at this time. Does Keith require an emergency psychiatric hold?
- yes
- no (Correct answer)
- varies according to state legislation Rationale: Keith does not meet the criteria for an emergency psychiatric hold. Although he is experiencing active delusions, his behavior does not threaten the safety of himself or others. Education, resources, and a plan for follow-up care should be established. Dakota Dakota is a 24-year-old who presents to the emergency department with his sister. He endorses taking a “handful” of pills after a fight with his boyfriend. He states that he regrets taking the pills, and he does not want to end his life. He denies active suicidal ideations or a plan. Dakota plans to stay with his sister for the next few days. Does Dakota require an emergency psychiatric hold?
- yes
- no (Correct answer)
- varies according to state legislation Rationale: Dakota does not meet the criteria for an emergency psychiatric hold. He does not have active thoughts of killing himself. He should be provided with resources for follow-up as well as information for the National Suicide Prevention Lifeline.
Rudy Rudy is a 42-year-old who was brought to the emergency department by his social worker. He was lethargic and disoriented when she found him at his “regular” spot in an encampment of unhoused individuals. Rudy was admitted for dehydration and his labs indicated severe malnutrition. Rudy has a history of schizophrenia with poor treatment adherence. He has no family in the area and has been living without housing for several years; his social worker endorsed that before this point, he had appeared healthy and had utilized available services for meals. Once medically stable, Rudy stated that he did not remember where to get food, and he was not sure how he got so sick. He does not wish to remain in the hospital. Does Rudy require an emergency psychiatric hold?
- yes
- no
- varies according to state legislation (Correct answer) Rationale: Rudy meets the criteria for a psychiatric hold in most states. He has a history of mental illness with poor treatment adherence, has no family support, and has been unable to care for himself; he meets the criteria for a gravely disabled individual and may be detained involuntarily for further evaluation. Nnenna Nnenna is a 22-year-old who was brought to the emergency department by the police after a car crash. The police officers state that Nnenna was crying and repeating, “just let me die” and the officers were concerned for her mental wellbeing. Nnenna's blood alcohol content is 0.12 g/mL. Upon interview, Nnenna has gross motor impairment and impaired judgment. She denies suicidal ideations, but she states it might be better for her to just die because her parents are going to be so upset after they find out about the accident. Nnenna's boyfriend met her in the emergency department and reported that she frequently drinks excessive amounts of alcohol. He plans to stay with her in her apartment overnight if she is released. Does Nnenna require an emergency psychiatric hold?
- yes
- no
- varies according to state legislation (Correct answer) Rationale: Nnenna meets the criteria for a psychiatric hold in some states. She is legally impaired due to alcohol consumption, and her boyfriend reports that she frequently drinks excessive amounts of alcohol. She also crashed her vehicle and states that she wants to die.
Khoudia Khoudia is a 34-year-old who delivered her second child one month ago. She presents to the emergency department with her husband and newborn. Her obstetrician called a referral to the emergency department after completing the Ask Suicide-Screening Questions tool which indicated an acute positive screen. Khoudia endorses frequent thoughts about killing herself in the past week and states she has been overwhelmed by the baby’s care. She states she has a plan to wait until the baby is asleep and then sit inside the garage with the car running. Khoudia refuses to be admitted to the hospital because she is breastfeeding; her husband voices a plan to hide the car keys and stay awake all night to keep her safe. Does Khoudia require an emergency psychiatric hold?
- yes (Correct answer)
- no
- varies according to state legislation Rationale: Khoudia meets the criteria for an emergency psychiatric hold. She presents a danger to herself; her husband’s safety plan, while admirable, is not realistic to keep her safe. The client should be provided with a breast pump and storage for breastmilk so that she may continue to breastfeed. Psychiatric Advance Directives Psychiatric advance directives (PAD) are unique legal documents that guide a client’s treatment preferences if they are having a mental health crisis and are unable to make decisions (NAMI, n.d.-a.). PADs may contain advance instructions, a health care power of attorney, or both. PADs help protect a client’s autonomy by detailing their preferred medications and treatment modalities, and by giving advance consent for treatment or admission. PADs may be useful for clients who experience episodes of acute psychosis, catatonia, mania, or delirium (NAMI, n.d.-a.). PADs are recognized in 25 states. Discover More Learn more about your state laws regarding PADS: https://nrc-pad.org/states/
Ethical Use of Restraints and Seclusion Clients at risk of imminent harm to themselves or others may require temporary seclusion or restraint until their condition is stabilized. Laws regarding the use of seclusion or restraints differ from state to state. It is important to understand the scope of practice for your state. Seclusion involves the involuntary confinement of an individual alone in a room or area from which the individual is prevented from leaving. Restraints can be both chemical and physical. Chemical restraints include any substance used to control a client’s behaviors, whereas physical restraints are devices that restrict a client’s movement. Physical restraints include both soft and leather limb restraints which can be applied to wrists, ankles, or both. Mittens are another form of less restrictive restraint. Seclusion or restraints should only be used to ensure the immediate physical safety of the client and others. Evidence is lacking to support restraint use to decrease falls, therefore other options should be considered (Abraham et al., 2020). Restraints should be used as a last resort only when less restrictive interventions have been ineffective to prevent harm. Restraints carry a risk of injury, including extremity fractures, suffocation, and even death. Seclusion and restraints should never be used as a means of discipline, coercion, retaliation, or for staff convenience. Ordering Restraints and Seclusion A face-to-face evaluation and written order are required to initiate restraints or seclusion for the management of violent or self-destructive behavior (American Psychiatric Nurses Association [APNA], 2022). The evaluation must be completed within one hour of the application of restraint or seclusion, although some state laws may be more restrictive. Restraints cannot be ordered as needed. Every 24 hours, an authorized licensed practitioner responsible for the client's care orders must evaluate and document the continued need for restraints, though some state or hospital policies may be more restrictive. Restraint orders should be discontinued as soon as safely possible. Discover More Learn about a client’s experiences with restraints while in inpatient psychiatric care: https://themighty.com/topic/post-traumatic-stress-disorder-ptsd/ Summary Severe mental illness afflicts 6% of all U.S. adults, which is higher among females, young adults aged 18- 25, and minority populations (National Institute of Mental Health [NIMH], 2022). Individuals with serious mental illness often have significant physical and mental health needs and comorbidities. These complex mental health disorders are often associated with significant diagnosis, treatment, and recovery challenges. They also may give rise to legal and ethical dilemmas, including involuntary mental health treatment. The psychiatric mental health nurse practitioner (PMHNP) plays an important role in the comprehensive treatment of these individuals.
