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Contributors
Nanci A. Swan Claus, RN, BS, BSN, MSN, FNP Nursing Instructor, University of Alabama at Birmingham, Birmingham, Alabama
Marcus Otavio Guimaraes Debiasi, DDS, MS-BMS, BSN-RN, CRNP-PMH Adjunct Instructor, University of Alabama, School of Nursing, Birmingham, Alabama
Jonathan S. Dowben, MD Medical Director and Senior Child Psychiatrist, Child and Family Behavioral Health Service, Brooke Army Medical Center, Fort Sam Houston, Texas
Susanne A. Fogger, DNP, PMHNP-BC, FAANP Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
Joan Grant Keltner, PhD, RN Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
Karmie M. Johnson, DNP, RN, PMHNP-BC Assistant Professor, School of Nursing, University of Alabama at Birmingham, Birmingham, Alabama
Peter C. Kowalski, MD Medical Director, Outpatient Services, Behavioral Health Center, Eastern Idaho Regional Medical Center, Idaho Falls, Idaho
Randy L. Moore, DNP, RN Assistant Professor, Veterans Affairs Nursing Academic Partnership with University of Alabama at Birmingham School of Nursing, Birmingham, Alabama
W. Chance Nicholson, MSN, PMHNP-BC Instructor, Nursing,
University of Alabama at Birmingham, Birmingham, Alabama
Gordon I.G. Pugh, MDiv, MPhil, BCC Chaplain, Pastoral Care, Children's of Alabama, Birmingham, Alabama
Richard A. Sugerman, PhD Professor of Anatomy (Emeritus), Director, Service Learning Projects, College of Osteopathic Medicine of the Pacific, Western University of Health Sciences, Pomona, California
Barbara Jones Warren, PhD, RN, FAAN, CNS-BC, PMH Professor of Clinical Nursing, Director of College of Nursing Psychiatric and Mental Health Nurse Practitioner Specialty, Interim Director Doctor of Nursing Practice Program, Ohio State University, Columbus, Ohio
Ancillary Writers
Linda Turchin, RN, MSN, CNE Associate Professor of Nursing, Fairmont State University, Fairmont, West Virginia Test Bank and NCLEX Review Questions
Linda Wendling, MS, MFA Learning Theory Consultant, University of Missouri St. Louis, St. Louis, Missouri TEACH for Nurses and PowerPoint Slides
Reviewers
Barbara B. Blozen, EdD, MA, RN, BC, CNL Department of Nursing, New Jersey City University, Jersey City, New Jersey
Lynn Bratchett, RN, BSN, MBA Assistant Program Director, Allied Health Associate Degree Nursing, Alameda Health Services, Alzheimer’s Services of the East Bay, St. Rose Hospital, Hayward, California
Catherine E. Grimsley, MSN, RN Undergraduate Program Director, Department of Nursing, Briar Cliff University, Sioux City, Iowa
Aida J. Sapp, PhD, RN, PMHCNS-BC, PMHNP-BC, LMFT Professor of Nursing, University of Mary Hardin-Baylor, Scott and White College of Nursing, Belton, Texas
Preface
“Of making many books there is no end, and much study is a weariness to the flesh.” Solomon said this way back around 950 bc. How did he know? I mean, he got it right on both ends. There are millions of books out there, and studying is hard, tiring work. However, another way to look at it is that what you are going through has been experienced by billions of people since Solomon’s time.
With King Solomon in mind, we have attempted to write a book that you will enjoy reading—at least for a textbook. We have tried to write in a clear, concise style. Of course, you will be the judge of whether that objective has been met. We deliver what we believe is a straightforward approach to psychiatric nursing. It is the psychotherapeutic management approach consisting of three interlinking parts we describe as Me, Meds, and Milieu. We emphasize how you will interact with psychiatric patients, the medications you will give to your patients, and how you will assist in making their environment more therapeutic. We hope you actually enjoy reading this text, and, even more, we hope you learn from it. With those hopeful thoughts in mind, we practice clarity and conciseness right from the beginning with this short preface. Good luck!
Teaching and Learning Resources
Norman L. Keltner
Debbie Steele
For Instructors
Instructor Resources on Evolve, available at http://evolve.elsevier.com/Keltner/, provides a wealth of material to help you make your psychiatric nursing instruction a success. In addition to all of the Student Resources, the following are provided for instructors:
• TEACH for Nurses Lesson Plans, based on the chapter Learning Objectives in the textbook, serve as ready-made, modifiable lesson plans and a complete roadmap to link all parts of the educational package. These concise and straightforward lesson plans can be modified or combined to meet your particular scheduling and teaching needs.
• PowerPoint Presentations are organized by chapter with approximately 400 slides for in-class lectures. These are detailed and include customizable text and image lecture slides to enhance learning in the classroom or in Web-based course modules. If you share them with students, they can use the note feature to help them with your lectures.
• Audience Response Questions for i > clicker and other systems are provided with one to three multiple-answer questions per chapter to stimulate class discussion and assess student understanding of key concepts.
• The Test Bank has more than 900 test items, complete with the
correct answer, rationale, cognitive level of each question, corresponding step of the nursing process, appropriate NCLEX format, Client Needs label, and text page reference(s).
For Students
Student Resources on Evolve, available at http://evolve.elsevier.com/Keltner/, provides a wealth of valuable learning resources for students. The Evolve Resources page in the front of the book gives login instructions and a description of each resource.
• An updated Evolve website for students includes NCLEX-RN review questions, answers to Chapter Critical Thinking Questions, Psychotropic Drug Monographs, and Video Lectures.
As is true of all nursing text authors, our goal is to present accurate and meaningful information to the student without the distraction of sexist language. Where possible, we have made every attempt to avoid the use of sexist pronouns by using plural nouns and pronouns or “his or her” rather than risk stigmatizing by gender. To avoid awkwardness of style, we have sometimes referred to the nurse as “she” and the patient as “he.”
Acknowledgments
The fact that Psychiatric Nursing warrants an eighth edition humbles me. In these many years in the field of psychiatric nursing, numerous people have guided my thinking, encouraged me at the right time, or even pushed me to develop my philosophy of and approach to psychiatric nursing care. I remember these individuals and their contributions to my life. I attempted to list all of them in past editions. However, in the seventh and eighth editions, I mention the great institutions I have worked in. In these places, I have learned, formed lifelong friendships, and earned a living so that I could raise and support a family. A list of these important institutions follows:
Stockton State Hospital in Stockton, California (15 years)
United States Army
VA Hospital
University of Wyoming (my first teaching position)
Baylor University
California State University, Bakersfield
University of Alabama at Birmingham
I am not sure how one thanks an institution, but I will try anyway. Dear SSH, US Army, VA, UW, BU, CSUB, and UAB: Thank you for giving me an interesting and rewarding career and for allowing me to provide a living for my family. Most sincerely, Norm
I also want to acknowledge my family of origin my mom, Gladys (1914–1984); my dad, Lawrence (1910–1989); my brother Hode (1938–2017) and his wife Brenda; and my sister Jennifer (Coeur d’Alene, Idaho) and her husband Paul. They all believed in me more than I did myself.
Finally, I dedicate this book to my six grandsons, Sam, Asher, Izzy, Axel, Billy, and Henry, and my three granddaughters, Addie, Millie Kate, and Audrey.
NLK
I would like to thank Dr. Norman Keltner for the rich experience of collaborating on the seventh and eighth editions of his nursing textbook. I also want to acknowledge the extraordinary work of researchers, educators, and practitioners who have contributed to the development of this Psychiatric Nursing textbook.
DS
UNIT I The Basics
1
Me, Meds, Milieu
Norman L Keltner
We dare not lengthen this book much, lest it be out of moderation and should stir men’s antipathy because of its size
Aelfric, Abbot of Eynsham (955–1020)
LEARNING OBJECTIVES
• Describe the components of psychotherapeutic management.
• Explain the way in which the balancing of psychotherapeutic management components forms a powerful therapeutic model of care.
• Recognize the relationship between the continuum of care and the psychotherapeutic management model.
• Identify the various levels of care within the continuum of care.
http://evolve.elsevier.com/Keltner
Where to start? You start with basics the basic tools you need to work with people who have mental health problems. Whether as a student or as a seasoned psychiatric nurse, when you look in the mirror and ask yourself, “What are my tools?”, the answer will be: “I
have Me, Meds, and the Milieu.” (Milieu is a French word for environment, but because it is/was commonly used in psychiatry, we will use it too.) This text consistently advances this simplistic model and calls the model psychotherapeutic management. Most often, instead of “Me,” we use the term nurse-patient relationship, but because you are the nurse in the nurse-patient relationship, the use of “Me” just helps to make the point. The psychiatric nurse has three ways to work with her patients (we will probably use the pronoun “her” most often but will work in “him” sometimes for all of the politically correct reasons): her interpersonal skills, her medication skills, and her ability to enhance (or create or construct) a safe and therapeutic environment. Thus we delightedly use the attention-grabbing chapter title, “Me, Meds, Milieu.”
Although we admit the model is simplistic, we do not believe it is simple to master. Learning to communicate therapeutically is a continuous process. Understanding psychiatric medicines is far from simple. It not only takes a lot of work, but it also hinges on how well you learned anatomy, physiology, and pharmacology. Anybody can give a pill, but a competent nurse understands the many dimensions of the drugs he gives. Finally, modifying an environment to make it both safe and therapeutic takes tremendous skill and consistency. The rest of this chapter explores the concept of psychotherapeutic management a simple model of organizing your thinking and your care. Following that discussion, the chapter provides an overview of various sources of mental health care and support the so-called continuum of care.
Psychotherapeutic management
Psychiatric nursing needs care models that are not only effective for patient care but that also can capitalize on the uniqueness of the discipline. Psychotherapeutic management proposes a real-world approach to psychiatric nursing care that recognizes the interdependence of the mental health profession yet exploits the strengths of psychiatric nursing. It seeks to answer the question, “What do psychiatric nurses do that is different from other mental health
professionals, particularly social workers, psychiatrists, and psychologists?”
Psychiatric treatment can be divided into five basic categories: (1) use of words, (2) use of drugs, (3) use of environment, (4) use of somatic therapies, and (5) use of behavioral conditioning. Psychotherapeutic management emphasizes the first three of these categories: (1) words from which nurses develop the nurse-patient relationship, (2) drugs, specifically psychotropic drugs, and (3) environment (as noted, the French word for environment, milieu, is often used). However, the nurse cannot effectively use these interventions unless she has a sound understanding of psychopathology (Fig. 1.1).
FIG 1.1 Psychotherapeutic management in the continuum of care is based on an understanding of psychopathology.
Stated another way, the student has three intervention tools to rely on:
1. Me (nurse)
2. Meds
3. Milieu (or environment)
One Size Does Not Fit All!
The authors also plead with you not to overlook the power of this paradigm just because it looks simple. You can approach every patient with this model in mind. Simply (there’s that word again), you can approach every patient by asking the following questions: “How should I talk with this patient?”, “What kind of medicine should he be taking?”, and “What are the environmental issues that will promote health and safety?”
One intervention might take priority over another depending on the situation. The particular approach depends on the patient’s diagnosis (i.e., psychopathology) and level of functioning. For example, the nurse learns to use different words when he speaks with a patient with a diagnosis of schizophrenia as opposed to a patient with a diagnosis of depression. More than likely, the patient with schizophrenia requires antipsychotic medications, whereas the depressed patient receives antidepressant drugs hence drug management is different. Finally, the patient with schizophrenia might need an environment that reduces stressors, whereas a key environmental concern for the patient with depression or bipolar disorder might be safety (e.g., suicide prevention). In other words, the psychotherapeutic management model recognizes that one size does not fit all.
Norm’s Notes
STOP!! Take a good look at this chapter. It will make a lot of sense because it gives you a simple approach for conceptualizing what you are doing with patients. When you work with patients, you need to focus on three things: (1) ME: how you will interact with them, (2) MEDS: the medications they need, and (3) MILIEU: how you can affect their environment. This approach arms you with a strategy. Now, although the framework is simple, the basics of the psychotherapeutic management approach are not simple far from it. You will spend the entire term understanding what goes into fleshing out this model.
Application of Psychotherapeutic Management Interventions
The application of psychopathology and the knowledgeable use of psychotherapeutic management skills extend beyond inpatient settings into various care settings, such as outpatient programs, residential services, and home care. The needs of the individual and the setting in which care is delivered influence the degree to which each component of psychotherapeutic management is provided within the continuum of care (Fig. 1.2).
FIG 1.2 Psychotherapeutic management model.
For example, individuals with depression in an inpatient setting benefit most when a therapeutic nurse-patient relationship, an antidepressant, and a well-managed milieu are available. When one component is missing from the equation, treatment is compromised. Just think about the possibilities when one part is missing. For example, what if the psychiatrist orders the right antidepressant (say, Lexapro), but the nursing staff does not carefully observe a potentially suicidal patient? The results could be disastrous! This simplistic example demonstrates that all components of the psychotherapeutic management equation should be present for patients to realize maximum benefit from nursing care.
Psychotherapeutic management: three interventions
Therapeutic Nurse-Patient Relationship
Distinguishing therapy from being therapeutic is crucial for the student of psychiatric nursing. Therapy is the focus of graduate level psychiatric nursing training, as well as the graduate programs in other disciplines. It is not taught at the basic nursing program level. What you will be taught is how to be therapeutic. Think about the difference, and savor it. You can learn to be a therapeutic nurse in the short time you are taking this course. When this course is completed, the student is not a therapist but should possess therapeutic skills.
Unit II is devoted to the “Me” dimension of psychotherapeutic management. A new vocabulary of words and concepts are discussed within a relationship context. Specifically, general communication skills, the nature of the nurse-patient relationship, working with groups of patients, working with the families of patients, and other related concepts are discussed.
Psychopharmacology
Unit III is devoted to the contribution of psychotropic drugs to psychiatric care, the responsibilities of the nurse, and essential information about these drugs. Most other textbooks do not provide a separate unit for these drugs, preferring to integrate the discussion into a disorders chapter. We would argue that the role of psychiatric medicines is so significant that a thorough treatment is a better approach. In fact, seeing a professional person for an emotional issue is almost synonymous with being prescribed a psychotropic med. Whether it should be that way or not is a debate worth having, but that is the reality of this hour of history.
Psychopharmacology is an important dimension in psychotherapeutic management because psychotropic drugs have enabled millions of people to live increasingly independent lives. However, drug intervention is neither always desirable nor appropriate,
