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Hospital-Based Psychiatric Nursing Care, Chapter 33
Hospital-Based Psychiatric
Nursing Care
• Inpatient psychiatric units developed in response to community
need-play vital role in the system of care
• Issues impacting hospital-based psychiatric units
• Changes in health care policy
• Decrease in reimbursement
• Issues impacting delivery of inpatient psychiatric services
• mental health parity legislation, health care reform, state mental health budget cuts,
shortened length of stay, workforce issues, recovery model philosophy, and stigma
Hospital-Based Psychiatric
Nursing Care
• Inpatient psychiatric care
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Account for 60% of all psychiatric admissions
Negative finance margins have downsized or closed many units
Average length of stay is 5 to 10 days
Crisis stabilization length of stay is 2 to 3 days
Most patients are admitted in the crisis stage with a treatment goal of
stabilization not remission
Hospital-Based Psychiatric
Nursing Care
• Indications for inpatient hospital
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Prevent harm to self or others
Stabilization to allow treatment at a less restrictive level of care
Patients with safety risks that must be monitored
Gravely disabled
Need for rapid, multidisciplinary, diagnostic evaluation
Hospital-Based Psychiatric
Nursing Care
• State Hospitals
• Provide highly structured care 24/7
• Number of state beds has decreased by 90% over the last 50 years
• Deinstitutionalization-Relocate funding from hospitals to community
programs – has created:
• Homelessness
• Jails and prisons as psychiatric hospitals
• Hospital emergency room overflow
• Violent crime
• 5% of homicides are committed by the 5 to 10% who are not receiving psychiatric
care
Hospital-Based Psychiatric
Nursing Care
• Partial Hospital programs (PHP)
• Designed to prevent relapse and avoid hospital admission
• Crisis stabilization
• Perform crisis stabilization to prevent hospitalization and develop problem solving and
coping
• Recovery-orientated
• Daily, goal-directed services for high risk patients
Hospital-Based Psychiatric
Nursing Care
• Nursing role
• Manage therapeutic milieu
• Provide stable environment and facilitates/implements individual treatment
plans
• Implementing caregiving activities
• Integrating and coordinating care delivery
• Therapeutic community was described by Maxwell Jones as the
inpatient environment with social interactions with staff and peers
Hospital-Based Psychiatric
Nursing Care
• Therapeutic milieu
• Set limits on maladaptive behaviors
• Teach/foster psychosocial skills
• Orientation and reality awareness
• Assertion – express self appropriately
• Occupations – hands-on activities
• Recreation – structured, constructive leisure activities
Hospital-Based Psychiatric
Nursing Care
• Therapeutic Milieu (cont.)
• 5 components of therapeutic milieu:
• Containment (provide for patient safety)
• Reduction of seclusion and restraint use is a high priority
• Support
• Increase self esteem
• Structure
• Predictable organization of time, place, and person
• Involvement
• Interact and attend to the patient’s social environment
• Validation
• Individuals are recognized
Hospital-Based Psychiatric
Nursing Care
• Nursing implications
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Physical safety
Education
Activities
Social interaction (involvement)
Acknowledge patients feelings (validation)
Hospital-Based Psychiatric
Nursing Care
• Safety is a priority of the nursing profession
• Areas of risk
• Aggression or violence
• Suicide attempts
• Elopement
• Seizures
• Falls
• Communicable diseases
Hospital-Based Psychiatric
Nursing Care
• Assessment for physical illness
• Patient and family education
• Essential for therapeutic progress
• Begin with an assessment for barriers i.e. lack of insight, denial, illiteracy,
visual or hearing deficits, and impaired memory
• Activities, groups, and programs
• Groups and programs are a cost-effective way to implement nursing care
Hospital-Based Psychiatric
Nursing Care
• Discharge planning
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Plan for discharge starts when patient is admitted
Nurse needs to assess for patient knowledge, needs, and resources
Include families
Multidisciplinary collaboration
Hospital-Based Psychiatric
Nursing Care
• Professional, regulatory , and accreditation standards
• Nurses
• American Nurses Association (ANA)
• State laws and regulations
• The Magnet Recognition Program of the American Nurse
Credentialing Center
• Hospitals
• Joint Commission is leading accrediting agency
• Their standards serve as a benchmark for other regulatory
agencies
• Federal
• Centers for Medicare and Medicaid Services (CMS)