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I. COURSE DESCRIPTION

Clinical application of theoretical concepts in meeting mental health care needs across the life span, incorporating the nursing process for clinical decision making. Clinical experiences with individuals and groups in acute care and community settings.SANU 205P is taught in half semesters (7 weeks). The clinical laboratory

hours willbe six each week. Pass/fail credit – 3 credit hours.

Prerequisite: SANU 104, SANU 104P Corequisite: SANU 205 II. CONCEPTUAL FRAMEWORK Health Patient Nursing Nurse Setting III. CLINICAL OBJECTIVES To meet these objectives, the student must apply knowledge from theory to clinical practice. Human Needs 1. Utilize the process of assessment to collect data relative to needs interferences

from the patient, patient records, family, and the health care team in the mental health setting. 2. Assist mental health patients in resolving human needs interferences, with

consideration of developmental and sociocultural factors. Nursing Process 1. Validate, cluster and interpret mental and physical assessment data to formulate

diagnoses for patients with mental health needs interferences. 2. Use the nursing process to develop and implement plans of care for mental health

patients, in accordance with established policies and procedures and in consultation with faculty.

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Role of the Nurse Provider of Care 1. Prioritize and address needs interferences/concerns of mental health patients in a

timely, safe and appropriate manner. 2. Provide care with respect for the patient's lifestyle and values.

Manager of Care 1. Collaborate with other members of the health care team to manage nursing care of patients with needs interferences related to mental health. 2. Foster the patient's independent functioning to maximum potential. Member of the Discipline 1. Function within the defined role of the student nurse in the mental health setting, in accordance with established policies and procedures. Communication

1. Examine own subjective feelings and reactions to beginning a clinical experience in mental health nursing and evaluate interactions with

patients as a basis for further evaluation of self awareness/self improvement.

2. Apply therapeutic communication techniques in developing relationships

with patients who have mental health needs interferences, with consideration of developmental and sociocultural factors.

3. Participate in group therapy and multidisciplinary team meetings,

practicing appropriate communication techniques. 4. Report needs and condition of assigned patients to faculty and appropriate staff in a timely and pertinent matter, with particular attention to changes. 5. Document appropriate mental status and physical assessments of patients and nursing care given.

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6. Respect and maintain confidentiality of all information related to mental health patients.

7. Using proper channels, initiate referral of the patient to appropriate mental health resources in the mental health setting or in the community.

Caring 1. Demonstrate empathy and unconditional acceptance of the mental health patient, irrespective of personal biases.

2. Demonstrate caring behavior that reflects an awareness of the dignity, worth and cultural values of mental health patients.

3. Demonstrate caring in interpersonal relationships with other members of the mental health team and with peers. Teaching Learning 1. Determine learning needs of mental health patients and their level of learning readiness, with consideration of developmental and sociocultural

factors. 2. Implement patient teaching appropriately in the mental health setting,

using either a student developed or standardized plan. Psychomotor Skills 1. Recognize potential for unsafe practice before performing skills. 2. Integrate cognitive, psychomotor and affective dimensions in the safe

performance of skills in the mental health care setting, recognizing

the need for assistance as necessary.

Responsibility/Accountability

1. Integrate ethical, moral and legal principles in providing nursing care to mental health patients.

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2. Demonstrate personal responsibility and accountability for own nursing practice in the mental health setting, with the guidance of instructor, and

in accordance with established policies and procedures. 3. Integrate self evaluation and instructor feedback to improve practice of

nursing.

Critical Thinking

1. Integrate and synthesize theories and concepts in understanding the

needs of mental health patients and in the delivery of safe care to them.

2. Utilize reasoning and decision making skills effectively in: developing

care plans, IPRs, community assignments, daily logs, post conferences

and critique of nursing research.

IV. METHODS OF INSTRUCTION

1. Observation and nursing care of selected patients in the psychiatric clinical setting.

2. Participation in clinical rotation group conferences (pre and post conferences).

3. Participation in psychiatric unit activities.

4. Reference readings.

5. Audiovisual aids - computer - assisted instructions, video programs, reference articles (Learning Resource Center, Library, Computer Lab, Behavioral Health

Services Unit of Spartanburg Regional Medical Center). Blackboard for handouts

and the Evolve Learning System – web address is http://evolve.elsevier.com

V. STUDENT RESPONSIBILITIES

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A. The student is responsible for the policies in the Associate Degree Program in Nursing Handbook and the USC Upstate Catalog. B. Clinical Practice (hospital)

1. Students are expected to be PRESENT, ON TIME, AND PREPARED FOR ALL CLINICAL EXPERIENCES.

2. In case of emergency or illness, students are expected to notify

the clinical instructor and/or clinical unit as early as possible PRIOR to the scheduled experience.

3. Students who miss a clinical experience must adhere to the ADN

Policy for clinical absence (see Policy). 4. Pre and postconferences are considered a part of the clinical experience

and attendance is required. Students are expected to organize and complete assignments in time to get to post conference at the designated time. Students are evaluated on participation in these conferences.

5. Students are expected to prepare for the clinical assignment.

Students who come to the clinical area unprepared may be dismissed and receive an unsatisfactory evaluation for the missed clinical day.

6. The faculty reserves the right to refuse clinical access at any

time during the semester to a student who has an unsafe practice/unsatisfactory clinical practice. Refer to the Policy for Unsafe Clinical Practice.

7. Students are expected to be appropriately dressed for all clinical experiences. (See Student Handbook and

guidelines for psychiatric unit dress requirements distributed by faculty.)

8. Students are required to maintain current safety training as mandated by OSHA.

9. During the semester, faculty/student interactive conferences will be scheduled as needed on an individual basis. Students are required to

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attend these conferences and the clinical evaluation conference at the end

of the semester at a time TBA. Students who do not schedule a final

evaluation conference will receive an unsatisfactory final grade in the

course or a grade of I in the case of extenuating circumstances.

10. All written and oral assignments must be completed and submitted in order to pass the course, although not all written assignments for the practicum are computed in the final course grade. Failure to complete work as assigned may result in an incomplete grade in the course.

11. Papers or other written assignments are due at the time designated by the instructor. Five(5) points will be taken off per day or any portion of the

twenty-four hours on any late paper or assignment to include Saturday, Sunday and holidays.

12. A maximum of five(5) points may be taken off on written assignments for

grammar, punctuation, and spelling. Papers should be typed or submitted in black ink.

13. Hazardous Weather - In the case of hazardous weather which prohibits

traveling or makes traveling dangerous, radio and/or TV announcements during that morning will be used as a guide.

VI. COURSE REQUIREMENTS

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The student will be evaluated in the clinical laboratory by the instructor. The student will be evaluated on the basis of his/her ability to apply theoretical principles, using the

nursing process in the care of patients with mental/physical health needs interferences. The student's performance in meeting clinical laboratory behavioral objectives will be evaluated in the following ways:

1. Observation by instructor of interactional skills with patients, families and health

team members.

2. Observation by instructor of performance of psychomotor skills. 3. Observation by instructor of the use of the nursing process in the clinical

laboratory setting. 4. Written and oral assignments. 5. Dialogue with instructor in the clinical laboratory setting. 6. Participation in pre and post conferences.

The student will receive a mid course report based on his/her progress toward meeting laboratory objectives as stated in the 205P Clinical Evaluation Tool. The instructor feedback will include any indicated suggestions for improvement in meeting clinical objectives. In the event the instructor recognizes difficulty with a student's progress, the student will be requested to meet for a conference with the instructor. The student may also request such a conference if he/she desires. Final clinical evaluation will be a summative report based on clinical laboratory objectives.

A policy for Unsafe Clinical Practice is included in this syllabus. The student must earn a satisfactory clinical evaluation in order to pass SANU 205P.

VII. Course Requirements A. Assignments 1. Daily Physical Assessments 2. Daily Mental Status Assessments

3. Daily Log submitted for each clinical day 4. Nursing Care Plan

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5. Interpersonal Process Recording of Interaction 6. Final clinical examination

Specific criteria for written and oral assignments are included at the end of this syllabus. Other clinical activities will be graded satisfactory/unsatisfactory. B. Final grades will be calculated as follows: 1. Clinical performance (Satisfactory/Unsatisfactory) . . . . 40%

2. Final clinical examination (comprehensive) . . . . . . . . . 40%

(to be given the last day of the clinical rotation) 3. Interpersonal Process Recording. . . . . . . . . . . . . . . . . 10% 4. Nursing Care Plan. . . . . . . . . . . . . . . . . . . . . . . . . . . 10% 100%

Under the USC Upstate Academic Honor Code, students are on their honor not to cheat, lie or steal. If a student witnesses another student doing so, it is the student’s responsibility to report the individual and the circumstances to an appropriate instructor or the Associate Chancellor for Student Affairs. Violation of this code may result in severe penalty which can include removal from the University.

-from the USC Upstate Statement of Student Responsibility

C. Grading Scale: A - 92-100 C - 78-81 B+ - 89-91 D+ - 75-77 B - 85-88 D - 70-74 C+ - 82-84 F - 69 and below

A minimum grade of 78 is required to pass this course. The ERI Test for Mental Health Nursing must be completed by each student at the end of this course. Failure to complete the ERI test will result in a grade of I (incomplete) for this course. VII. Required Text:

Varcarolis, E. (2002). Foundations of Psychiatric Mental Health Nursing. 4th edition Philadelphia: W.B. Saunders Company.

Ackley, B. & Ladwig, G. (2002) Nursing Diagnosis handbook. 5th edition St.Lous:

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Mosby Inc.

The ERI Test for Mental Health Nursing must be completed by each student at the end of this course. Failure to complete that test will result in a grade of I

(Incomplete) for this course.

The ERI test is given outside of regular class time in SANU 205.

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UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE PROGRAM IN TECHNICAL NURSING

POLICY FOR CLINICAL ABSENCESBecause attendance in clinical laboratories is extremely important and the number of days are limited, there should be no absences for clinical labs. The following provisions for makeup are as follows:

SANU 104P - For the first absence, with permission of the instructor, the student

will complete a clinical makeup day at a date designated by the instructor.

For the second absence, with permission of the instructor, the studentwill complete a clinical makeup paper. Any additional absences will

resultin an unsatisfactory.

*SANU 201P, 203P, 204P, 205P - After the first absence, with permission ofthe instructor, the student will complete a clinical makeup paper. Anyadditional absences will result in an unsatisfactory in the course. If a

studentis absence the first clinical day, the day of orientation, the student

mustmeet individually with the instructor for the amount of time necessary

forthe instructor to adequately prepare the student for safe clinical

practicein the mental health setting.

GUIDELINES FOR PAPER FOR CLINICAL MAKEUP

General Instructions - In the event of a clinical absence, the student will consult with the clinical instructor regarding permission to complete the following assignment. The paper must have a grade of satisfactory (78 or above) to make up the absence. If a paper has to be resubmitted for a student to achieve a satisfactory grade, this will be reflected in the clinical evaluation. The instructor reserves the right to have the student return to the clinical area to make up the missed day if instructor deems necessary.

Format - Adhere to logical, systematic format, correct grammatical construction, clarity of presentation and proper of all components (use headings and subheadings). Paper is to be typed and in APA format. The deadline for submission of the paper will be determined by the instructor. (10 points)

Clinical Situation - You will be given a clinical situation for your specific clinical

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course. Use this information to complete the following.1) Review of Literature - summarize current information from professional

journals. Use at least 4 different articles on the topic. Includereferences. (30 points)

2) Plan of Care - use the above information in developing a plan of care for

the patient in the clinical situation. (30 points)3) Discuss the ethical issues that the above situation presents. Support

yourconclusions with documentation from at least 2 reference articles. (30

points)

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UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE PROGRAM IN TECHNICAL NURSING

Directions for the Psychiatric Clinical Rotation

1. Report to the Behavioral Health Unit of Spartanburg Regional Healthcare System at 6:45

am or 12:30 pm time assigned, depending on your assigned rotation.

2. Bring paper for note taking. Instructors may request that you bring your textbook on

specific days. You need to bring your clinical syllabus each day. You will need your watch

with second hand, but you will not need scissors.

3. Street clothes are worn by the nursing staff on the unit. You must follow the dress code

specific to the Spartanburg Regional Healthcare System. Professionalism in attire and in

your attitude should be your guide. The uniform code of the school and that of the hospital will be enforced. Please observe the following guidelines:

a. Always wear your USC Upstate name pin at all times while on duty (MBSON & and SRMC policy).

b. Skirts must be long enough to permit you to participate in unit activities. Slacks

are most appropriate unless you have some objection to wearing them.

c. Shirts, blouses or tops must be worn tucked in unless specifically made to

wear out. Shirts and/or blouses must not be see through or sheer material. Tops

can not have slogans, trade names, etc. written on them.

d. No t-shirts

e. No sleeveless blouses (SRMC policy).

f. Hospital owned scrub dresses and pants will not be worn to and from the

hospital (SRMC policy).

g. Do not wear heels. Tennis shoes are fine but should not have holes in

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them.Sensible type walking shoes are necessary. You must wear hose or

socks withwhatever type shoes you wear.

h. No clothing of denim material is to be worn (Mary Black Hospital and SRMC policy).

i. Jump suits are not permitted.

j. Artificial nails may not be worn.

k. No dangling earrings in the patient care setting.

l. Neither opened toe shoes nor opened heel shoes.

m. No ornaments may be worn in any visible pierced sites other than the ear

in patient care areas (no tongue rings).

n. Long hair to be secured so it does not fall across the face and front of the

shoulders.

o. No perfume, after shave, other fragrances or heavy make-up.

p. Please observe the Associate Degree Program policy regarding jewelry.

Pre and post conferences are held on the unit. In case of an emergency, a message may be left

for you by calling 560-6185.

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UNIVERSITY OF SOUTH CAROLINA SPARTANBURGMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE PROGRAM IN TECHNICAL NURSING

STATEMENT OF UNSAFE PRACTICE The following may be considered as unsafe practice by students: 1. Failure to use nursing process effectively, demonstrated by such behaviors as

lack of knowledge of the patient's diagnoses, treatments, or medications; failure to follow safety precautions for patient such as side rails, restraints, position of patient, acts of omission or commission, including utilization of correct principles in implementation of skills, the documentation of care, and the administration of medications.

2. Failure to take nursing action when such action is essential to the health and safety of the patient.

3. Performing nursing activities which are detrimental to the health and safety of the patient.

4. Attending clinical laboratory while under the influence of alcohol or drugs.5. Failure to recognize the influence of own attitudes, values, beliefs and behavior on the

care of patients.6. Deliberately giving false or inaccurate information regarding nursing care.7. Failure to assume responsibility for completing nursing care.8. Performing interventions without adequate preparation or needed supervision.9. Some examples of unsafe behaviors are as follows:

-medicating a patient without the permission/supervision of instructor-medicating or performing a treatment without verifying the doctors order

before

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completing the task-leaving an infant unattended-violation of HIPPA

*NOTE: These are not all inclusive.

CONSEQUENCES OF UNSAFE PRACTICE The consequences of unsafe behavior are determined by the nature of the behavior exhibited and the situation in which it occurs. 1. Unsafe practice may result in immediate failure.2. Students may be sent home for the clinical day.3. Repeated unsafe behaviors or failure to correct an unsafe behavior will result in failure. The student will not be allowed to continue in the clinical area and must withdraw from the course and any corequisite courses.4. See specific course Clinical Evaluation Tool for further performance criteria.

Date Revised 7/01

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UNIT ITOPIC: The Therapeutic Nurse-Patient Relationship

I. Objectives: After completing this unit, the student will be able to: A. Differentiate between social and therapeutic interactions. B. Identify the stages of the nurse/patient relationship and the appropriate activities of each stage. C. Describe techniques and skills effective in nurse/patient interactions. D. Identify barriers to therapeutic communication. E. Discuss the therapeutic vs. non-therapeutic use of self disclosure. F. Describe common specific problems in communicating with mentally ill patients and identify nursing interventions. G. Develop therapeutic relationships with assigned patients.

H. Evaluate interpersonal relationships with patients, identifying strengths and areas of needed improvement.

II. Content Learning Activity

A. Communication Techniques Varcarolis: Chapter 10 and Chapter 11 Varcarolis: Chapter 9-Assessment Strategies and the Nursing Process B. Communication Barriers *LRC Assignment: VC14 - 33.0 Techniques of Therapeutic Communication (20") C. Guidelines for Interviewing VC14 - 33.1 Blocks to Therapeutic Communication (17") D. Social vs. Therapeutic Relationships VC14 - 33.2 Interactions for Study (13")

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E. Phases of Therapeutic Relationships *If seen in earlier courses, review as necessary

F. Characteristics of Therapeutic Students will develop one-to-one inter- Relationships actions with assigned psychiatric patients. Students will also evaluate interactions and document them. G. Anxieties of Patient/Nurse Students will complete an process recording in the Therapeutic Relationship interaction on a selected patient during the psychiatric clinical rotation.

Completion of a satisfactory IPR is essential for a satisfactory psychiatric clinical evaluation.

UNIT IITOPIC: The Use of the Nursing Process in the Care of Psychiatric Patients/Cultural Factors

and Mental Health I. Objectives: After completing this unit, the student will be able to: A. Discuss the influence of culture on the health beliefs and practices of individuals. B. Describe the relationship between cultural factors and the symptoms of mental

illness. C. Discuss feelings and behaviors that influence the student's ability to interact with individuals of another culture. D. Describe the communication problems encountered when caring for patients from

multicultural backgrounds. E. Identify components of the mental status assessment. F. Describe various tools of psychosociocultural assessment. G. Perform and document basic physical and mental status assessments

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on assigned patients, respecting patients’ privacy and protecting confidentiality. H. Using data gathered, determine appropriate NANDA diagnoses for actual and/or

potential mental health needs interferences.

I. Identify teaching/learning needs of patients with disruptions in mental health, withconsideration of developmental levels.

J. Establish realistic, measurable and appropriate goals for patients, in consultation with the patient, faculty and other mental health team

members. K. Develop a plan of care for mental health patients with consideration of patient's

developmental and sociocultural needs. L. Prioritize care needs for patients in consultation with faculty.

M. Implement care specific to meet the human needs interferences of mental health patients, with incorporation of cultural and developmental

concepts.

N. Evaluate goal attainment according to criteria and modified care needed based on evaluation.

II. Content Learning Activity A. Assessment 1. Physical Assessment- Varcarolis: Chapters 7, 9 24 hour 2. Mental Status Assessment 3. Assessment of Cultural Using the nursing process, students Factors will provide nursing care for assigned psychiatric patients. a. Attitudes of health care givers b. Language barriers Students will perform basic physical to interactions assessments as well as mental status c. Health practices assessments. Age-related needs, of specific ethnic needs related to cultural diversity, groups levels of anxiety, and major ego

defense mechanisms will be assessed. d. Cultural influences

on coping behaviors. B. Nursing Diagnoses 1. NANDA Psychiatric Nursing Diagnoses 2. DSMIV/Medical Diagnoses C. Planning 1. The Nursing Care Plan

2. Growth/Development and Culturally Related Factors D. Intervention

1. Implement Nursing Measures to Promote Physical/Emotional Comfort

2. Identify patient teaching/learning

needs

3. Implement Patient Teaching to Reduce Anxiety and Increase Coping Skills E. Evaluation 1. Patient Responses to Nursing Interventions and Interactions 2. Outcomes 3. Student's Self-Appraisal of Nursing Interventions and Interactions

UNIT III TOPIC: Intervention Modes - Psychiatric Treatment I. Objectives: After completing this unit, the student will be able to: A. Identify types of therapies/activities used in the treatment of psychiatric patients.

B. Discuss the purposes of therapies/activities used in the milieu. C. Describe the nurse's role in therapies/activities used in the milieu. D. Participate in psychiatric unit treatment modalities with assigned patients.

II. Content Learning Activity

A. Biofeedback Varcarolis: Chapters 34, 35 and 36, Ch. 12

Students will be given information in B. Assertiveness Class class lecture and in clinical conferences C. New Patient Orientation about treatment modalities. D. Music Therapy Following presentation of information, E. Exercise Class and at the discretion of the instructor F. Plant Therapy the student will be a participant/observer G. Occupational Therapy in milieu therapies and activities. H. Group Therapy

I. Community Meeting ECT (Electroconvulsive Therapy) Hand out on Blackboard J. Multidisciplinary Team Conferences

K. Electroconvulsive Therapy

UNIT IV TOPIC: Legal Implications of Psychiatric Mental Health Nursing I. Objectives: After completing this unit, the student will be able to: A. Describe the balance sought between patients' rights and the following

legal/ethical issues basic to accountable nursing practice: 1. Informed consent 2. Confidentiality 3. Documentation 4. Right to treatment 5. Right to refuse treatment B. Discuss and give examples of a patient's civil rights. C. Describe the advocacy role in providing nursing care to the mentally incompetent.

D. Differentiate between voluntary and involuntary commitment. E. Differentiate among the categories of involuntary commitment.

F. Differentiate between the rights of voluntary and involuntary patients. G. Discuss the Standards of Care for Psychiatric Nursing Practice.

H. Identify nursing implications for the right to refuse treatment and other important patient rights.

I. Describe the evolution of the community mental health movement and current

factors impacting community care. II. Content Learning Activity A. Historical perspective Varcarolis: Chapter 8 and appendix B B. Types of admission to in Be prepared to respond to each of the patient psychiatric facilities objectives listed above. C. Present trends/rights issues/ Handout on ECT (electroconvulsive therapy)

community focused care in is available on Blackboard mental health D. Psychiatric nursing in the

acute setting E. Psychiatric nursing in the long-term care setting F. Strategies for assuring quality psychiatric nursing care TOPIC: Aggressive Behavior/Preventive Techniques/Intervention I. Objectives: After completing this unit, the student will be able to: A. Discuss models of the etiology of aggression.

B. List common precipitants of anger. C. List the disorders/population groups at high risk for violence to self or others.

D. Self evaluate personal feelings about working with patients who are victims ofabuse and with abusers.

E. Discuss verbal intervention. 1. Describe non-threatening body language. 2. Describe the types of communication.

3. List communication techniques most therapeutic. F. Describe the procedure for physically subduing a person who is exhibiting

aggressive behavior. 1. Describe the role of the leader. 2. Describe the role of the team. 3. Describe the procedure for "taking down" a person who is exhibiting

aggressive behavior. 4. Describe treatment of the individual who has acted out following

application of restraints. 5. Discuss the patient's civil rights pertaining to restraint and seclusion.

G. Discuss feelings team members may experience when restraining a person.Discuss follow-up needs of : Patient who has acted out, other patients on the unit, and staff.

II. Content Learning Activity

A. Theories of the Etiology of Aggression Varcarolis: Chapter 24 B. Groups at Risk for Aggressive

Behavior Handout on Aggressive Behavior in C. Identification of Potentially Syllabus

Aggressive BehaviorD. Verbal Intervention in Aggressive BehaviorE. Physical Intervention in Aggressive BehaviorF. Reactions of Health Care Team

Members to Aggressive Behavior

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE NURSING PROGRAM

SANU 205P-Mental Health Nursing PracticumLab Focus - Geropsychiatric Nursing

1. Interact (communicate) with patients and staff on the unit.

2. Identify types of therapies/activities used in the treatment of patients on the unit.

3. Use appropriate communication techniques when participating in group activities on the geropsychiatric unit.

4. Discuss the admission requirements for admission to the geropsychiatric unit.

5. Describe the nurse’s role in the therapies/activities used in the milieu.

6. Identify frequently prescribed psychiatric medications used on the unit.

7. Discuss common problems related to administration of psychotropic medications to the geropsychiatric patient.

8. Identify common DSM-IV diagnoses seen on the geropsychiatric unit.

9. Identify 3 nursing diagnoses along with appropriate interventions, to address the needs of patients suffering with Alzheimer’s disease.

10. Identify 3 community resources that might be appropriate for a select patient who is being discharged from the geropsychiatric unit.

11. Write a brief overall reaction to today’s clinical experience.

Objectives are to be completed in writing and submitted to the clinical instructor.

Bj Fall’04

UNIT VTOPIC: Psychopharmacology

I. Objectives: After completing this unit, the student will be able to:

1. Describe the mechansim of action of antipsychotic agents, antidepressants,antianxiety agents and antimanic agents.

2. Identify frequently prescribed psychotropic medications.

3. List the common side effects and adverse reactions of antipsychotic agents,antidepressants, antianxiety and antimanic agents.

4. Identify frequently used medications which interact with psychotropicmedications.

5. Evaluate the effect of psychotropic medication on the patient’s health status.

6. Assess assigned patients with regard to actual and potential health problemsrelated to psychotropic medication therapy.

7. Demonstrate an understanding of ethical and legal issues surrounding administration of psychotropic medications.

8. Identify teaching/learning needs of the patient and/or family regardingpsychotropic medications.

9. Discuss the issue of compliance vs. non-compliance in psychotropic medicationtherapy.

II. Content Learning Activity

A. Review of biologic basis for Videos on psychotropic medications to psychopharmacology be shown on psychiatric unit or campus lab.

B. Actions/effects/side effects/patient teaching needs/ nursing Varcarolis: Chapter 3implications of:

1. Antipsychotic agents2. Antidepressants 3. Antianxiety agents 4. Antimanic agents

5. Anticonvulsants (mood stabilizers)

C. Use of antiparkinsonian/and anticholinergic pps. 549 and 552(Table)Agents to treat acute EPS

VC14-05 – “Medication Issues in Mental Health”

D. Common problems related toadministration of psychotropicmedications:

1. The suicidal patient2. The paranoid patient3. The drug-abusing patient4. The geriatric patient5. The adolescent patient

E. Legal/Ethical issues related toadministration of psychotropicmedications

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE PROGRAM IN TECHNICAL NURSING

SANU 205PInteraction Recording Directions

PURPOSE: The written interaction is designed to give the student an opportunity to practicecommunication skills and to evaluate the effectiveness of those skills. It is notexpected that the student will be perfect with communication skills but it is expected that the student will be able to evaluate the effectiveness of therapeutic communication techniques and the behaviors of the nurse and patient.

DIRECTIONS: On plain white paper (8½ x 11 inches) write or type the following. It is yourresponsibility to make this paper easy to follow and readable.

1. Date of Interaction

2. Patient Data:

Initials Marital StatusAge Educational LevelSex DSM IV – R DiagnosisNationality

3. Patient’s Family History:Number of Family MembersRelationship to Patient to Family (i.e., mother with three grown children; grandmother with three grandchildren)

4. Description of Patient and Environment at the time of interaction – provide a physical descriptionof the patient. This should be adequate enough for the reader to form a mental picture of the patient.Describe area of psychiatric unit in which interaction took place.

5. Objective for Interaction

6. Introduction to InteractionDescribe the reason you selected your objective. Give any overview or information that will assistthe instructor in understanding the segment of interaction you chose.

7. Evaluation of Interaction a. Record verbatim what the nurse and patient said. (Choose a five to ten minute segment of the

interaction that best represents your abilities.)b. After each segment of interaction, include in parentheses the following:

nonverbal actions, tone of voicec. Address each segment of the nurse’s communication, evaluating the following:

1) What communication skills and techniques did you use to facilitate therapeuticcommunication?

2) Why did you say what you did?3) Did you have any blocks to communication?

4) How could you have said it better?5) How did your nonverbal actions and tone of voice affect your interaction?6) What were your feelings when you said this?

d. Address each segment of the patient’s communication, evaluating the following:1) What is the patient really saying? (Include defense mechanisms, level of anxiety,

grief, anger, etc.) Use theory to explain pt’s verbal and non-verbal communication.2) How did the patient’s nonverbal actions and tone of voice validate the verbal

communication?3) In the patient’s communication, did you identify any ego strengths?4) Explain how the patient’s responses in this segment of the communication support or

fails to support the DSM-IV diagnosis.5) What feelings were evoked in you by the patient’s communication?

8. Overall Evaluationa. Did you meet your objective?b. If so, describe how you met your objective.c. If not, describe why you did not meet your objective.d. How could you have improved the overall interaction?

9. Grading Scale – See Grading Scale for IPR for Evaluation Criteria.

B. Jackson/M. Tone – Spring 2003

UNIVERSITY OF SOUTH CAORLINA UPSTATEMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE PROGRAM IN TECHNICAL NURSING

GRADING SCALE FOR IPR

Name: _____________________________________________ Clinical Instructor: _________________

CATEGORY POSSIBLE POINTS POINTS AWARDED

PATIENT DATA 5

FAMILY HISTORY 5

DESCRIPTION OF PATIENT &ENVIRONMENT 5

OBJECTIVE 10

INTRODUCTION TO INTERACTION 10

DOCUMENTATION OF INTERACTION

VERBAL 5

NONVERBAL 5

EVALUATION OF INTERACTION

NURSE’S COMMUNICATION 20

PATIENT’S COMMUNICATION 25

OVERALL EVALUATION 5

LEGIBILITY OF EVALUATION 5

TOTAL = ______________ ____________100

TURN THIS PAPER IN WITH IPR, PLEASE!

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE PROGRAM IN TECHNICAL NURSING

MENTAL HEALTH ROTATIONDAILY LOG

Name ________________________________________ Date of Patient Care _____________

1. What learning needs of the patient did you identify?

2. Did you do any pt. teaching today? If so, describe.

3. What caring behaviors did you exhibit in your nursing practice today?

4. In evaluating your practice today, how could you improve your nursing care of the patient with a mental illness?

5. Write a brief overall reaction to today’s clinical experience.

Revised Fall 2002B. Jackson/MJ Tone

MENTAL STATUS ASSESSMENT (to accompany nursing care plan)SANU 205P

Student: ____________________________________Patient Initials: ______ Sex: ______ Age: ______ Date of Care: ______Under each category, circle the descriptors that apply to this patient. In each comment section add additional brief comments for clarification or support of your assessment.I. GENERAL APPEARANCE

A. Dress B. Posture C. Facial Expressionappropriate erect sad

bizarre slumped angryinappropriate tense/rigid suspiciousunkempt unusual anxioushygiene: appropriate bizarre warm/friendly

impaired elated makes eye contactother

D. Motor Behaviortremorsticsrestlessslow/retardedhyperactiveagitatedgrimacingposturingrepetitive movementsabnormal gaitcompulsions

Comments:

II. SPEECHA. Flow B. Volume

normal normalrapid loudpressured softretarded monotonemutism hostile tonereduced quantity

Comments:

III. THOUGHT PROCESSES – Describe the characteristics of the patient’s response:

A. Flow/Formlogical tangentialityretarded neologismsspeeded perseverationblocking present clang associationsassociative disorder flight of ideasconcrete thinking echolaliacircumstantiality attention span

poverty of speech word salad

B. Content – Central Theme: What is important to the patient?delusions (type) religiosityillusions preoccupationideas of reference suicidal ideationphobias homicidal ideationsomatic concerns ruminationsparanoia obsessionshallucinations (type) poverty of speechdepersonalization

Comments:

IV. INTELLECTUAL ASSESSMENT

A. Intellectual Functioning B. Orientationadequate vocabulary timegeneral knowledge fund personability to read/write placeability to abstract situation

C. Memory D. Judgment (according to history)recall of recent events goodrecall of remote events impairedexhibiting confabulation

E. Insightrecognizes illnessrecognizes effects of illness of lifeaccepts responsibility for own actionsdemonstrates adaptive coping strategies

Comments:

V. AFFECT

A. sadangryfearfulelatedflat/bluntedlabilecongruent with speech/behaviorother

Comments:

VI. ASSESSMENT OF ANXIETY:

level of anxiety _____________________________________________________

objective & subjective data to support level of anxiety noted:_________________

__________________________________________________________________

VII. COPING MECHANISMS (Defense Mechanisms): How does the patient cope with stress:

reported by patient __________________________________________________

identified by nurse __________________________________________________

VIII. SOCIOCULTURAL ASSESSMENT:

Erikson’s developmental stage __________________________________________

role in family _______________________________________________________

occupation ________________________________________________________

hobbies/recreational activities/interests __________________________________

support system _____________________________________________________

IX. PATIENT’S PROBLEM IN PATIENT’S WORDS:

________________________________________________________________________

________________________________________________________________________

________________________________________________________________________

X. PREVIOUS HOSPITALIZATION AND MENTAL HEALTH TREATMENT

________________________________________________________________________

XI. PATIENT’S DSM-IVTR DIAGNOSIS: _________________________________

________________________________________________________________________

XII. IDENTIFIED PREDISPOSING FACTORS: (genetic influences, past experiences, drug or alcohol use, existing conditions)

________________________________________________________________________

________________________________________________________________________

XIII. IDENTIFIED PRECIPITATING EVENTS: ____________________________________

________________________________________________________________________

XIV. PSYCHOPATHOLOGY/THEORIES OF ETIOLOGYWrite a summary, in your own words, of the major etiological theories of your patient’s diagnosis. Include genetic, biochemical, and psychosocial theories. Describe typical behaviors, symptoms, and characteristics of your patient’s diagnosis. Individualize the psychopathology to your patient. Attach a separate paper with this component of the assessment (XII) to your Mental Status Assessment Form.

XV. NURSE’S ASSESSMENT OF PATIENT’S LEVEL of SELF-ESTEEM: (Circle one)

High Moderate Low

XVI. BEHAVIORS ASSOCIATED WITH A STAGE OF GRIEVING(Circle stage that applies if grief is an identified reaction in your patient.)

Denial Anger Bargaining Depression Acceptance

XVII. COMMUNITY RESOURCES APPLICABLE TO PATIENT/FAMILY: __________

________________________________________________________________________

________________________________________________________________________

XVIII. Medications Please list all patient's medications on the medication work sheet and attach to your assessment form. Identify the psychotropic meds, state the reason drug is used, side effects, and nursing implications related to the drug.

XVIII. BASED ON YOUR MENTAL STATUS ASSESSMENT OF THE PATIENT, DEVELOP THREE COMPLETE MENTAL HEALTH (NANDA) NURSING DIAGNOSES USING THE ADN PROGRAM CARE PLAN FORM.

Fall 1994/J. ThaxtonRevised Fall 2004/B. Jackson

UNIVERSITY OF SOUTH CAROLINA UPSTATEMARY BLACK SCHOOL OF NURSING

ASSOCIATE DEGREE PROGRAM IN NURSING

SANU 205PMedications (you must address all psychotropic medications)

Medication Dose and Route Ordered

Reason for Medication being

Prescribed

Side Effects/Adverse Reactions

Nursing Implications

AGGRESSIVE BEHAVIOR/PREVENTIVE TECHNIQUES/INTERVENTIONS

Anger is a normal response to frustration or threat. Everyone experiences anger on occasion. Appropriate expression of anger can be healthy, but open expressions are generally considered inappropriate in our society. Angry behavior may be expressed on a continuum ranging from irritation to loss of control manifested in violence. Violence is behavior that is physically assaultive, risking injury to the self, others, and the environment.

ETIOLOGY OF AGGRESSION: Please refer to pages 665-670 of Varcarolis.

PRECIPITANTS OF ANGER:

Threats, losses, conflict, confusion, misperceptions, overwhelming stress, unemployment, history of being abused, unmet needs, frustration, suspiciousness, panic attacks, drug influence, organic disorders, toxic reactions, paranoia, criticism by others, victimization, not getting one’s way, hallucinations, delusions, inability to communicate effectively, and being a member of a violent subculture.

GROUPS AT RISK FOR VIOLENCE TO SELF OR OTHERS:

The psychotically ill, 15-25 year olds (especially males), those under influence of alcohol/drugs, the disoriented, those with organic disorders, any individual with illogical thought processes, especially paranoia, individuals with history of recent aggression or past violence.*** Some theorists believe the most likely predictor of violence in the future is aggressive behavior in the past.

Prevention of violence is preferable if it is possible. With careful observation and empathy, the nurse may be able to anticipate a violent outburst.***Staff need to not be too authoritarian, controlling, inflexible, or verbally aggressive themselves. Staff attitudes and behavior can have a positive impact on keeping patients’ behavior from escalating into violent outbursts.

Staff should be alert for cues: loud, pressured speech, pacing, clenching or pounding fists, tightening of jaw and/or facial muscles, changes in affect, growing irritability, cursing or muttering obscenities, increasing restlessness.

VERBAL INTERVENTION:Most potentially violent patient situations can be “defused” by a nurse using appropriate communications in a courteous and calm manner. Do: offer to help, ask how you can help, keep voice calm and moderate, do not use threatening words or curse words in retaliation, hear patient out -- it is important to let him say all he needs to say -- no matter how illogical or untrue his comments are -- much tension is dissipated in his saying what he wants to say. Nurse’s speech should be concise, clear, spoken slowly and with assurance.***It is thought valuable to call the patient by title, “Mr. Jones” – “Mrs. Smith”. The psychological purpose here is that you are showing respect and treating the person as an adult. The implication is that you expect him to act like an adult and to reciprocate the courtesy. Do not be drawn into a shouting match with patient. Do not laugh or smile inappropriately -- the angry patient needs to be taken seriously. Nurse has to try hard not to get defensive. Remember, nurse is role modeling healthy, adult behavior. Keep

stressing your desire to help.

RECOMMENDED NON-THREATENING BODY LANGUAGE:

Keep hands out of pockets, do not cross arms over chest, best position -- arms at sides with palms open and outward, allow more body space than usual -- angry person needs 4x more. Do not block doorways. Make eye contact but do not stare intently constantly -- this can be very threatening to a paranoid person -- also, nurse needs to keep an eye on patient’s hands in case he does strike out. Some believe it is best to stand more at a right angle than directly in front of patient so he doesn’t feel as ‘hemmed in.’

PROCEDURE FOR PHYSICALLY SUBDUING AGGRESSIVE PATIENT:

Each episode of violent behavior varies in cause and circumstances. The same guidelines will not always be sufficient. The nurse uses judgment and past experience in handling such situations. Often one relies on “gut level” feelings for a sense of what action is best. Hospital staffs need crisis management training and it needs to be reviewed regularly. Some hospitals have special codes and/or special teams trained to intervene. The nurse must familiarize her/himself with the protocol wherever employed. Before physically “taking down” a patient, one last attempt should be made to get him to calm down. Ask the patient to come to a more private place to talk. Sometimes, getting the patient away from the listeners standing by is a useful first step in calming him down. Offer to hear all he wants to say. Tell him you can see he is upset. Offer prn medication if there is an order, if not, get one. A patient who is on the verge of violent behavior is usually experiencing a panic level of anxiety and antianxiety medication may definitely be needed. If all efforts to “talk down” fail and it is thought necessary, the patient must be physically managed. Nurses have the right to use physical force to prevent patients from injury. The nurse should never risk being hurt by failing to take adequate precautions for her/his own safety. To take down:

1. Have a designated leader -- only the leader should talk to the patient. Multiple voices

may confuse patient.

2. Four or more staff members are needed -- one for each limb -- this is minimum – without sufficient help, someone may get injured. (Back up help or hospital security should becalled if needed).

3. Another staff member needs to be responsible for looking after other patients (and

visitors if they are in the area). Other patients may find such episodes very frightening

and they need reassurance of their own safety.

4. All staff taking down patient should remove any potentially harmful objects -- pens,

stethoscopes, watches, name tags, scissors, eyeglasses, etc. -- from their persons.

5. The patient is told calmly, but firmly that if he cannot control himself, staff will have to,

in order to keep him or anyone else from getting hurt. The leader does the talking.

6. If necessary, then, the staff members move in quickly, each one taking hold of the

limb for which that person has designated responsibility. If possible, staff gets the

patient off his standing base and into a horizontal position, face down. This is the

preferred position. The patient is then transported to a seclusion room. In some

facilities, he may be taken to his room and placed in restraints on the bed. The leader

or another staff member goes in front to clear the way.

7. Before a patient is left in a seclusion room, his clothing must be checked for potentially

harmful objects. There are times when a patient will be put in seclusion without any clothes on. This intervention is needed when the patient is a danger to himself. Any belts, scarves, jewelry or ties should be removed. The shoes may need to be removed. A seclusion room should be free of furniture, have only a mat or mattress, and these should have no linens. At this time, a prn dose of tranquilizing medication is frequently given (per physician’s orders), I.M., to help calm the patient, reduce his anxiety, and assist him in gaining control of his behavior.

8. Prior to leaving the room, the nurse tells the patient again that he is not going to be

allowed to hurt himself, others, or hospital property and says clearly and firmly, “when

you can control your behavior, we will take you out of here.” No arguing is engaged

in at this time, regardless of the patient’s attempt to do so. The staff members then

back out of the room and the door is locked.

9. There must be a physician’s written order on the chart to seclude or restrain a patient.

The psychiatric staff may have approval to seclude the patient, then get the order, if a

crisis situation existed and the welfare of patients was at stake. An observation schedule

must be put in place immediately. Many seclusion rooms have camera and audio

monitors. The seclusion rooms on the psychiatric unit at SRMC do. Documentation must

be begun immediately of the observations.

FOLLOW-UP NURSING CARE:

Frequently, patients who have been given medication will sleep for awhile. The nurse will make judgment about the patient’s readiness to come out of seclusion and will usually spend some time assessing and talking with the patient before making the decision. The nurse uses judgment in deciding when to talk to the patient and whether to do so alone. As soon as possible, the patient’s right to the least restrictive environment possible should be honored. It is important that the patient not be treated in a punitive manner afterward. Staff should indicate their willingness to continue working with him. He needs help in learning alternate coping methods. Staff must show control. Patients are afraid of losing control. Staff should not appear anxious or ambivalent, but should continue conveying message, “We will not let you hurt yourself or others.” Stress again, “We are here to help you.”

IMPORTANT STAFF MEASURES:

Immediately after physically “taking down” any patient, the staff should review what happened. Issues to consider are: 1. Can precipitants for the patient’s outburst be identified? Prevented in future? 2. Evaluation of staff’s actions. Could it be done better next time? Does the procedure need to be modified? Does the leader need to point out any inappropriate actions of staff? This should never be done in the middle of subduing a patient but immediately afterwards. 3. Ventilation of feelings by staff. Their anxiety needs to be dissipated, a “debriefing” needs to occur.