N5100+Course+Intro

Introduction to
Psychiatric
Nursing
Dr. Marissa DeCesaris Siegel

N5100 Fall 2024
Learning Objectives
• Overview of nurses’ role in mental health
• Therapeutic relationship and boundaries
• Nursing process and CJMM in psychiatric nursing

• Overview of psychiatric assessment
• Intro to the mental status exam
Why do I have to take this class?
• Mental health disorders are everywhere (and increasing)
• Only 40% of adults with mental illness get treatment
• People with mental health disorders also get sick
• Increasing rates of violence against nurses
• Medical illnesses can mimic mental health disorders
• Medical illnesses/injuries can cause adjustment & grief reactions
Stigma
Components Levels
• Knowledge • Intrapersonal
• Attitudes • Interpersonal
• Behavior • Family
• Community
• Structural
Person-First Language
Preferred Non-preferred
• Person with a mental health • Mentally ill, crazy, insane
disorder, person receiving mental
health treatment • Labeling person as
• Person with ___ disorder (person disorder (ie:
with schizophrenia, person with
borderline personality disorder)
schizophrenic, borderline)
• Person who uses substances/drugs • Addict, drug addict,
or person with a substance use
druggie, junkie, drunk
disorder
• Compliant • Adherent
Vulnerable Populations
• Children
• Older adults
• Adults with developmental delays
• Homeless individuals
• Refugees
• Military
• LGBTQIA+ individuals
Theory of Interpersonal Relationships
(Hildegard Peplau)
• Everyone is susceptible to mental illness
• Mental health and illness exist on a continuum, not a
binary
• Mental health symptoms should be looked at in their
sociocultural context
• Nurses should work with patients to achieve a common
goal
Key Therapeutic Relationship Skills
• Presence
• Empathy
• Unconditional positive regard
• Patient-centered care
• Therapeutic communication
Therapeutic Relationship
• Planned
• Goal-directed
• Structured (time, place, content)
• Professional
• Nurse acts in best interest of patient
• Maintaining boundaries is the NURSE’S responsibility
Boundaries
• Purpose: maintain safety
• Patient
• Nurse
• Transference
• Counter-transference
• Boundary crossing vs. violation
Self-disclosure
• For benefit of patient, NOT nurse
• Not a shortcut to building rapport
• Consider risks vs. benefit to client

• Less is more
• Monitor patient response
Touch
• Ask permission first, and for each part of interaction
• Consider clinical purpose
• Consider trauma history
• Over sensitive to touch
• Overly permissive to touch
• Okay to decline
Tips on Maintaining Boundaries
• Starts at the first interaction
• Clear, firm limits
• Provide explanation for limits
• Choose wisely what you insist on
• Offer flexibility when possible
• Do not reward negative behavior
• Reward positive behavior
• Utilize support from co-workers and supervisors
Treatment Types
• Voluntary
• Involuntary
• Mandated
Medical Diagnoses
DSM-5 ICD-10
• Psychiatry only • All fields of medicine
• F codes (primary
diagnosis)
• Z codes (psychosocial and
environmental factors)
Where do psychiatric nurses work?
Health Residential
Schools Home care Hospitals
centers treatment
Substance
Group Street Public Crisis
use
homes medicine health centers
treatment
Case
Mobile Nursing
manageme Prisons
crisis teams homes
nt
Mental Health of Nurses
• Vicarious trauma (aka secondary trauma, compassion
fatigue)
• High rates of burn-out
• Increased workplace violence
• Increased rates of substance use
Nursing Process & CJMM in
Psychiatric Nursing
Review Content from Other Courses
• HPI & OLDCARTS (5010 Part 1)
• SBAR (5010 Part 2)
• Clinical judgment measurement model (5010 Part 2)
• SDOH (5020)
• SMART goals (5020)
• Trauma-informed care (5020)
• Motivational interviewing (5020)
• Neurotransmitters (5070)
• Pharmacology principles (5070)
Nursing Process
Original Updated
• Assessment • Assessment
• Diagnosis • Analysis
• Planning • Planning
• Implementation • Implementation
• Evaluation • Evaluation
Nursing Clinical Judgment Model
• Recognize cues
• Analyze Cues
• Prioritize Hypotheses
• Generate Solutions
• Take Action
• Evaluate Outcomes
APNA Psychiatric Mental Health
Nursing Standards of Practice
• 1: Assessment
• 2: Diagnosis
• 3: Outcomes identification
• 4: Planning
• 5: Implementation
• Coordination of care, health teaching & promotion, consultation,
pharmacologic/biological therapies, complementary/integrative therapies, milieu
therapy, therapeutic relationship, counseling & psychotherapy
• 6: Evaluation
Assessment Domain Information to Assess
(Recognize Biological VS, PMH, current medication,
Cues) substance use, physical ROS
Psychological Chief complaint, HPI, MSE,
psychiatric treatment history
Sociological Living situation, income,
occupation, education, social
supports, family structure and
dynamics, hobbies/interests,
trauma history
Spiritual Spirituality, culture, religion,
personal preferences for care
Analysis What do you think is going on with
(Analyze Cues) this patient?
What patterns can you see in

assessment data?
What role do SDOH play in

presentation?
What are the patient/family’s

strengths?
Planning What are the most immediate safety
(Prioritize risks?
Hypotheses)
What needs must be met first?
What are the actual vs. potential

problems?
What is the most concerning finding?

What is the desired outcome for each
problem? (SMART goals)
Planning
(Generate What is the patient’s priority?
Solutions)
Is this goal feasible in the context of
SDOH?
What are the anticipated barriers to

achieving this goal?
What are the risks vs. benefits of each

outcome?
Implementation (Take
Action)
• Nursing interventions to meet
goals
• Safety
• Engagement in activities
Therapeutic communication
• Coping skills
• Patient/family education
Evaluation (Evaluate Outcomes)
• Rating scales
• SDOH
• Treatment adherence
• Lab values
• Adverse medication effects
• Safety
• Subjective report
• Patient
• Collateral
Psychiatric Assessment
Overview
• Introductions
• Chief complaint
• HPI
• Psychiatric history
• Medical history
• Social history
• MSE
• Patient goals and concerns
Initiating the Conversations
• Provider introduction (name, pronouns, role)
• Permission to assess (what you want to do and why,
permission to decline all or some of assessment)
• Patient introduction (name, pronouns, DOB, allergies)
HPI
• Chief complaint (in patient’s own words)
• OLDCARTS
• Onset (including any precipitating events/stressors)
• Location (when/where symptoms occur)
• Duration (include any fluctuations)
• Characteristics (symptoms)
• Aggravating factors
• Relieving factors
• Treatment
• Severity
Psychiatric History
Social History
Medical History
Spiritual Assessment
Mental Status Exam
Purpose of the MSE
• Snapshot of psychological
functioning at a point in time
• Establish baseline
• Assess changes
• Identify risks
• Identify areas of concern for
further assessment
MSE Components
Appearance and grooming Psychomotor activity Attitude Speech
• Hygiene, dress • Normal, slow/decreased, • Cooperative, uncooperative, • Volume, rate, rhythm, tone
appropriate/inappropriate for restless/increased/agitated, hostile, irritable, friendly, • Pressured, mumbling, hesitant,
weather tremor, EPS evasive, withdrawn, guarded, slurred, impoverished
eye contact
Mood Affect Thought process Thought content

• Emotional state, usually a • Observed expression of emotion • Normal: linear/goal-directed, • SI, HI, delusions, obsessions,
feeling • Quality (depressed, dysphoric, logical ideas of reference, response to
• Stated in patient’s own words euthymic, elevated, irritable, • Abnormal: illogical, tangential, internal stimuli
tearful, bizarre, anxious) circumstantial, flight of ideas,
• Congruency with mood loose association, disorganized,
• Range thought blocking, increased
response latency
Perceptual disturbance Insight Judgment

Cognitive
• Hallucinations (visual, auditory, • Awareness and acceptance of • General problem-solving,
• Orientation: person, place, time,
olfactory, gustatory, tactile) condition decision-making, and ability to
situation • Good, fair, poor, maintain safety
• Depersonalization, derealization • Level of consciousness • Intact, fair, poor
• Concentration
• Memory
Eliciting Patient
Strengths
• What is something you know so well
that you could teach it to someone else?
• What is something that you can
build/make/do?
• If you could open any business, what
would it be?
• What is something you are passionate
about that moves you to action?
• What moment or event has caused you
to grow the most?

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Introduction to

Dr. Marissa DeCesaris Siegel

• Nursing process and CJMM in psychiatric nursing

• Consider risks vs. benefit to client

What patterns can you see in

What role do SDOH play in

What are the patient/family’s

What are the actual vs. potential

What is the most concerning finding?

What are the anticipated barriers to

What are the risks vs. benefits of each

Mood Affect Thought process Thought content

Perceptual disturbance Insight Judgment

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