Community mental health nursing

• Before 1840, there was no known tx for individuals who were mentally ill. they were removed from the community to a place where they could do no harm to themselves or others
• in 1841, Dorothea Dix, a former school teacher started a campaign that resulted in the establishment of a number of hospitals for the mentally ill

• the mentally ill population grew faster than the number of hospitals, creating overcrowding and poor conditions
• the the 1940s and 1950s, a number of federal acts were passed, attempting to  improve the quality of care for the mentally ill

• in 1963, the community mental health centers act was passed, calling for the construction of community health centers
• deinstitutionalization (the closing of state mental hospitals and discharging of mentally ill individuals had begun
• however, in the 1980s, federal funding was reduced and the number of community health center was diminished

• 1. occured rapidly without sufficient planning for transitioning into the community
• a. 1979 in MA
• 2. few had support system, living arrangement, sheltered, employment, OP tx
• a. homesless
• b. admissions to nursing homes
• 3. Many left untreated, elders, working poor, homeless, people previously cover funds that have been cut out
• 4 results
• a. more persistently mentally ill presenting in the ed needing crisis intervention
• b. increase in hospital admissions
• c. repeated confrontation with law enforcement officials

• discharge as soon as pyschosis is controlled
• least restrictive settings/methods
• care mandate only for clients who pose threat to self or others/gravely disabled
• right of self-determination
• 1. right to tx
• 2. inform consent
• 3. right to refuse meds

• Cost containment by prospective payment was initiated in 1983, drastically affecting the amount of reimbursement for health care services
• client are being discharged from the hospital with a greater need for aftercare than in the past, when hospital stays were longer
• outpt services have become an essential mental health care system
• DRGs diagnostic Related groups- all based on dx

• primary prevention:
• - defined as reducing the incidence of mental disorders within the population
• - nursing in primary prevention is focused on targeting groups at risk and providing educational programs
• diminished harmful stressors

• interventions aimed at minimizing early symptoms of psychiatric illness and directed toward reducing the prevalence and duration of the illness
• accomplished through early identification of problems and prompt initiation of effective treatment
• nx
• recognize of s/s
• provision of referral for tx
• providing care

• reducing the residual defects that are associated with severe and persistent mental illness
• accomplished by preventing complication of the illness and promoting achievement of each individual's maximum level of functioning

nursing care at the tertiary level of prevention can be administered on an individual or group basis and in a variety of settings such as inpt hospitalizaton day or partial or partial hospitalization, group home or halfway house, shelter, home health care, nursing home, and community health centers

• individuals experiencing maturational crisis
• - adolescence
• - marriage
• - parenthood
• - midlife
• - retirement

• identity v role confusion (erikson)
• issues of control
• need  for support from parents
• issues include:
• - self esteem
• - body image
• - peer relationship
• - educate
• - sexuality
• - drug and alcohol abuse

• issues include:
• synchronization of two lives
• difference in religion, ethnicity, social status, or race
• need for communication and compromise

• issues include:
• total responsiblity for another human being
• parent- infant bonding
• changing husband wide relationships
• knowledge about stages of growth and development

• issues include:
• age related physiological changes
• relationship with adult children
• relationship with aging parents
• death of parents
• empty nest syndrome

• issues include:
• - negative feelings related to lack of productively
• - loss of self worth, depression
• - financial issues
• ambialence in retirement
• who they are
• set new goals
• support groups ways to spend time

• povery
• high rate life changing events
• environmental conditions
• trauma

• direct correlation between poverty and emotional illness
• May have to do with
• - inadequate and crowded living conditions
• - nutritional deficiences
• - medical neglect
• - unemployment
• - homeless

• large number if significant events occurring in close proximity decrease a persons ability to deal with stress
• ex: death of love ones
• chx in body images
• physical illness

• environmental conditions can create situational crisis
• ex: tornados floods

• traumatic experiences outside the usual range of human experience
• ex

• assistance required when disruptive and age inapproriate behaviors become the norm
• family can no longer cope with the situation
• inpt care may be required for:
• - CD
• - adjustment disorder
• - eating disorder
• - substance related disorder
• - depression and anxiety disorder s

• common problems in marriage
• substance abuse
• disagreements on issues of
• - sex
• - money
• - children
• - gender roles
• - infidelity

• ex of reasons for intervention with parents include:
• - physical, emotional, or sexual abuse of a child
• - physical or emotional neglect of a child
• - nirth of child with special needs
• - dx of a terminal illness in a child
• - death of a child

• individual may be unable to integrate all the changes that are occuring during this period, resulting in
• - depression
• - anxiety
• - substance abuse

• when individuals are unable to successfully grieve for this part of their lives, it can result in
• - depression
• - suicidal ideation

• approx 100,000 persons with mental illness redie in public mental hospital
• deinstitutionalizatoin occured so rapidly that there was no time for planning for the needs of these individuals before they reentered the community

• identified a number of barriers to care of the seriously mentally ill
• - fragmentation and gaps in care for children
• - fragmentation and gaps in care for adults with serious mental illness
• - older adults with mental illness are not receiving care
• - mental health and suicide preventionand not national priorities

• - americann will understand that mental health is essential to overall health
• - mental health care will be consumer and family driven
• - disparties in mental health services will be eliminated
• - early mental health screening, assessment, and referral to services will be common practices

• excellent mental health care will be delivered and research will be accelerated
• technology will be used to access mental health care and information

• community mental health centers
• program of assertive community tx (PACT)
• day-evening tx/partial hospitalization program
• community residential facilities
• psychiartric home health care

• US homeless est 250,000 and 4 million
• 39% younger than 18
• 25%between 25-34
• 6% are ages 55-64

• more men are homeless
• 23% families
• ethnic groups:
• - 37% blacks
• - 41% whites
• - 10% hispanics
• - 5 % single
• -7 % mix
• mental illness and homelessness

• Schizo
• bipolar
• substance abuse
• depression
• neuro-cognition disorder
• contributing factos to homelessness among the mentally ill
• 1. deinstitutionalization
• 2. poverty
• 3. lack of affordable housing

• malnutrition
• alcholism
• thermoregulation
• TV
• HIV
• special needs

• types of resouces
• - homeless shelters
• - health-care centers and storefront clinics
• - mobile outreach units

• goal: help pt with severe and persistent mental illness stay out of the hospital
• assist pts in developing community living skills
• provide individualized care in pt's home
• medication compliance, access services, financial help, transportation
• services 24/7 team approach

• dx of major mental illness or substance abuse requirewd
• often elderly
• nurses need in-depth knowledge of psychpathology, psychopharm, how medical/physical problems can be influenced by psych impairments
• medication monitoring safe self administration of medications, monitor compliance and side effects
• nurse must always remember- he/she is a guest in the client's home

• coordinates all aspects of pt care
• integrates multiple services and reduces fragmentation
• interdisciplinary team
• lifeline:
• - assess tx
• - very important to take
• - care of pt

• id and outreach/interaction- develop trust
• assessment and development of data base
• planning- mutually agreed upon goals
• implementation- CM is coordinator of client care is key, function in community, ie enhancing ADLs maintain regular contact
• coordination- service plan between all providers- test appts
• monitoring
• evaluation- continualy monitor and evaluate client's response

• assessment- situation and ability to function
• planning- pt directed, collab with other professionals and family
• implementation- CM is coordinator of care- referrals to others to provide services, at times CM providers
• coordination- CM organizes, secures, intergrates multiple services- test, appts, etc
• monitoring- pt response and progress, reduces fragmentation through accurate tracking
• evaluation- goal met? need to revise plan?

• primary care/mental health services
• - community based primary care settings
• - providing mental health promotion, education case findings, diagnostic assessments, routine tx and referral
• universal access to basic mental health package
• - establishing a minimum benefit package ensuring access to MH services throughout peoples lives