Customization of patient-centered care is essential.
Lifespan Considerations
Children and Adolescents:
Social and environmental factors.
Developmental stage.
History of trauma.
Attributes of the Mentally Healthy Child:
Trust, sense of security and safety.
Use of appropriate coping skills.
Mentally Ill Children: Points to Consider
Delayed or inadequate diagnosis and treatment due to:
Ability to express self/describe problem.
Variations about normal behavior/developmental task.
Parental fears/cultural biases and norms.
Assessment:
Mood/anxiety, developmental stage, behavioral, and eating disorders.
Use HEADSS (Home, Environment, Education/Employment, Activities, Drug and Substance Use, Sexuality, Suicide/Depression, Safety).
Older Adults
Assess for functional abilities (ADLs).
Economic and social status.
Environmental factors (residential structures).
Physical assessment.
Use standardized tools:
Geriatric Depression Scale (Short Form).
Michigan Alcoholism Screening Test for Geriatric Clients.
Caregiver Role Strain Assessment.
Safety at home (falls, ability to complete ADLs).
Conducting Client Interviews
Ensure quiet environment with adequate lighting.
Maintain your own safety.
Stand or sit at the same level with the client.
Introduce self, ask for the client’s preferred name.
Maintain appropriate eye contact and non-verbal communication.
Include family if the client wishes (must consider HIPAA).
Obtain detailed medication history.
Summarize the interview and ask for feedback.
Diagnosis of Mental Illness and the DSM-5
Published by the American Psychiatric Association.
Uses: Identification of mental health diagnoses.
Fluid document, changes over time.
Standardized assessment findings.
The Nursing Process
Examples of common diagnoses for plan of care.
Rule of physical before psychosocial and actual before at-risk.
Serious Mental Illness
Chronic (persistent or recurrent) mental disorder.
Remissions and exacerbations.
Ability to perform ADLs affected.
Often their own lives and/or the lives of others are at risk.
Role Changes and Mental Health
Losses: Employment, divorce, retirement, death.
Predictable and unpredictable role changes.
Change can be stressful and can lead to mental health strains.
Assessment following role changes:
Health status, ability to function.
Living conditions, level of information.
Coping and self-management.
Previous mental health history.
Support network.
Life Events and Mental Health
Even happy events can cause stress and anxiety; coping mechanisms can fail.
Especially cumulative events.
Legal and Ethical Issues in Mental Health
What is Ethics?
A set of moral principles about right and wrong.
Fundamental principles of moral conduct.
Why mental health nursing ethics:
Protection of patient rights.
Promotion of professional practice.
For patient safety.
Rights of the Mental Health Patient
Fundamental human rights:
Humane treatment (without prejudice, discrimination, or bias).
Right to medical/dental care.
Right to vote, obtain a driver’s license.
Right to legal services.
Specific mental health rights:
Right to have consent for treatment and refusal of treatment.
Interpreter services.
Confidentiality (Protected by HIPAA).
Plan of care, follow-up, and review of care.
Right to legal counsel, communication with family, and health professionals.
Freedom from physical or chemical harm including abuse and neglect.
Psychiatric advanced directive.
Provision of least restrictive care possible without being a threat to themselves or to others.
Ethical Principles
Autonomy: Respect a person's freedom to choose what's right for them.
Beneficence: All choices for a patient are made with the intent to do good.
Non-maleficence: Do no harm.
Justice: Treat and provide care fairly to all patients.
Fidelity: Keeping a commitment (promise) based on the virtue of caring.
Veracity: The principle of telling the truth.
Confidentiality
The right to privacy (HIPAA).
Client information cannot be shared with a third party without their written consent.
Client information can only be shared with health personnel directly caring for them.
Legal duties that seem to go against HIPAA:
Disclosing HIV status, warning and protecting others.
Reporting child and vulnerable adult abuse.
Sources of Information About Nursing Ethics
ANA Code of Ethics for Nurses (new version 2025!).
Patient Care Partnership.
The Nurse Practice Act (state-specific).
Legal advice.
Interprofessional health team.
Religious and spiritual counselors.
Types of Admissions: Informal and Voluntary
Informal Admission: Least restrictive, client not a threat to self/others.
Can leave the health facility anytime, even against the advice of the health team.
Voluntary Admission: Can be initiated by the client/guardian.
Client is competent, may discontinue admission or refuse treatment anytime.
The psychiatrist/health team may evaluate the client before release.
Types of Admissions: Temporary Emergency Admission
Medical health provider may initiate admission of a client for emergent care. In the case that it is against the client’s will, law enforcement is sometimes involved.
Client is unable to make their own care decisions but still may refuse medications.
Evaluation by a psychiatrist is required for this admission.
Client may be admitted for a maximum of 15 days.
Duration of admission may vary according to local laws and patient care needs.
Texas: Emergency Detention Order (EDO) 48 hours weekdays/72 hours weekends.
Very common for a client to be evaluated medically first.
Types of Admissions: Involuntary Admission
If the client is considered harmful to self/others, involuntary admission can be initiated.
The client is admitted to a mental health facility for a relatively long period of time.
Client is a threat to themselves/others and unable to maintain self-care.
The client is evaluated and found to require mental health care based on the following criteria:
Client is mentally ill, likely to harm self/others.
Client is severely disabled or cannot meet basic self-care needs.
Client is not able to seek voluntary treatment when they need it. (Determined by a judge)
Involuntary Admission, Continued
May be initiated by a family member, psychiatrist, legal guardian, or primary care provider.
Two physician evaluations are required.
Client may seek legal review anytime, legal advocate.
Duration: Up to 60 days, then legal/psychiatric review is required.
Client is considered competent with rights unless otherwise determined by the courts.
Long term admission: Imposed by a court for 60-180 days or longer.
Client Rights Regarding Seclusions and Restraints
Seclusion (Discussion):
What is seclusion?
Who can order seclusion?
How long does a seclusion/restraint last?
What are the indications?
When is seclusion wrong?
What are some less restrictive measures?
What is a temporary timeout?
Limits for Seclusion
18 years and older = 4 hours
9-17 years = 2 hours
8 and younger = 1 hour
Duties of the nurse during patient seclusion.
Can the nurse initiate seclusion?
During seclusion:
Complete assessment and documentation every 15 minutes (or follow protocol).
Renewable every 24 hours following face-to-face evaluation by the physician.
High risk for injury during seclusion.
High risk for emotional damage.
Legal Issues: Laws of Tort
Intentional and unintentional torts.
The law is supreme, always.
Nurses need to know federal, state, and local laws related to mental health care.
Tort: A civil wrong committed against another, may include damage to people or property.
Tort is a willful action and is likely to be more common in mental health settings.
Intentional Torts
False imprisonment.
Assault.
Battery.
Unintentional Torts
Negligence: Failure to provide appropriate/adequate care to clients in violation of one’s professional obligation (code of ethics, facility policy).
Negligence must be proven.
A professional is liable when the following are met:
The nurse had the professional obligation to protect, the duty was breached, and their neglect directly caused an injury.
It must be proven further that if the act of protecting was done, the injury would not have occurred.
Malpractice
Malpractice is a form of professional negligence.
In malpractice, professional standards are compromised.
The health professional fails to provide standard care and causes harm to the client.
Clients who suffer negligence or malpractice may seek redress in a civil court.
Nurses are held to Nurse Practice Act - each state has their own - in place to protect the public, not to protect nurses.