Mental Health Exam 1

What does a mental health assessment consist of?

· Focused Physical assessment

· Psychosocial history

· Mental status exam

· Screening tools

- Lifespan Considerations

What does a psychosocial history consist of?

· Cultural/religious/spiritual considerations

· Support systems

· Diet

· Sleep patterns

· Depression, anxiety, thoughts of suicide

· Coping mechanisms

· Alcohol/recreational drug/tobacco use

· Physical activity

· Medication history

· Use of vitamins/supplements/OTC meds

· "feel safe at home?"

What does a mental status examination (MSE) consist of?

· LOC

· Physical appearance

· Behavior

· Cognitive/intellectual

· GCS

What does a mini-mental state examination (MMSE) consist of?

· Orientation to time & place

· Attention span, ability to count backward

· Memory & recall

· Language, ability to write

· Pain!!

What standardized tool would you use with mentally ill children?

· HEADSS

Home

Environment

Education/employment

Activities

Drug

Substance use

Sexuality

Suicide/depression

Safety

What standardized tools would you use with mentally ill older adults?

· Geriatric depression scale

· Michigan alcoholism screening test for geriatric clients

- Mini-Mental State Examination (MMSE)

What is the Diagnostic & Statistical Manual of Mental Disorders (DSM-5)?

American Psychiatric Association Manual

- Used to identify mental health diagnosis and standardized assessment findings

What are the rights of the mental health patient?

· Humane treatment

· Right to medication/dental care

· Right to vote, obtain a driver's license

· Right to legal services

What are some specific mental health rights for patients?

· Right to have consent for treatment & refusal

· Interpreter services

· Confidentiality

· Right to legal counsel, communication with family & health professionals

· Freedom from physical or chemical harm including abuse & neglect

· Psychiatric advanced directive

· Provision of least restrictive care possible without being a threat to themselves or to others

Beneficence

The quality of doing good

Autonomy

The client's right to make their own decisions

Justice

Fair & equal treatment for all

Fidelity

Loyalty & faithfulness to the client (keeping a promise)

Veracity

Honesty when dealing the patient (telling the truth)

What is an informal admission?

· Least restrictive, not a threat to self/others

· Free to leave at any time, unless at risk for themselves

What is a voluntary admission?

· Can be initiated by client/guardian

· Considered competent, so can refuse treatment and medication

What is temporary emergency admission?

· Client is unable to make their own care decisions

· Evaluation by a psychiatrist is REQUIRED for admission

· May be admitted for a max. of 15 days

What is involuntary admission?

· Client enters facility against their own will for an indefinite period of time

· Client must be evaluated by a judge

· Up to 60 days

What is long-term involuntary admission?

Must be imposed by courts

Time varies from 60-180 days

Which type of patient is seclusion contraindicated?

Suicidal patients

What are the limits for seclusion?

· 18 & older - 4 hr

· 9-17 yr - 2 hour

· 8 & younger - 1 hour

What are the intentional torts?

· False imprisonment

· Assault

· Battery

- invasion of privacy

What is an example of false imprisonment?

Confining a patient to a seclusion room when it is NOT a part of their treatment

What is an example of assault?

Making a threat to a client

OR approaching the patient in a threatening manner

What is an example of battery?

Touching a client in a harmful way

What are the unintentional torts?

· Negligence

· Malpractice

What is an example of negligence?

A patient needs CPR, and it was not given to them in a timely manner

What is an example of malpractice?

Medication error

Characteristics of the therapeutic milieu - physical setting

· Unit should be clean

· Setting should include comfortable furniture

· Color scheme should be appropriate for client age

· Floors such be attractive, clean & safe

· Traffic-flow considerations should be conductive to client & staff movement

Characteristics of the therapeutic milieu - health care team member responsibilities

· Promote independence for self-care & growth

· Treat clients as individuals

· Allow choices for clients

· Apply rules of fair treatment

· Model good social behavior

· Work cooperatively as a team

· Maintain boundaries

· Promote safe & satisfying peer interactions

· Practice open communication techniques

· Promote feelings of self-worth & hope

Characteristics of the therapeutic milieu - emotional climate

· Clients should feel safe from harm

· Clients should feel cared for & accepted by staff

What are the roles of the nurse in a therapeutic nurse-client relationship?

· Embrace an attitude of life-long learning

· Remain patient-centered

· Encourage positive behaviors

· Be empathetic

· Anticipate client's needs

· Be consistent

· Value individuality

· Put effort into the relationship

· Be available

· Learn from feedback

What is transference?

Occurs when the client views a member of the health care team as having characteristics of another person who has been significant to the client's personal life

What is countertransference?

Occurs when a health care team member displaces characteristics of people in their past onto a client

What is the orientation phase of therapeutic relationships?

· Introduction (AIDET)

· Discuss confidentiality

· Build trust by establishing expectations

- set goals with the client

· Explore the client's needs

What is the working phase of therapeutic relationships?

· Perform ongoing assessments to plan & evaluate

· Encourage client to problem-solve

· Promote the client's self-esteem

· Remind the client about date of termination

What is the termination phase of therapeutic relationships?

· Discuss ways for the client to incorporate new healthy behaviors into life

· Provide opportunity to discuss thoughts & feelings about termination & loss

· Summarize goals & achievements

· Express own feelings about sessions to validate experience with client

· Make plans for future & accept termination as final

Focus & goals for individual therapy?

· Focus on needs & problems, create therapeutic relationship

· Goals: Better decision-making strategies to help live productive lives, develop strong sense of self

Focus & goals for group therapy?

· Focus: Help develop healthy relationships within a group setting

· Goals: Learn about self & others, improve quality of life, gain coping skills, improve interpersonal relationships, decrease isolation, obtain feedback

Focus & goals for family therapy?

· Focus: on needs of family & improve functioning for each member

· Goals: Learn how to deal with mental illness within family, improve understanding

Role of community setting (primary care) for mental health care?

· Includes clinics, schools, & day-care centers, partial hospitalization, substance treatment facilities, & home healthcare

· Nurses help to stabilize or improve clients' mental functioning within a community. Also teach, support, & make referrals

What is the role of telehealth?

· Meets the needs of those who cannot attend physical in-person treatment

· Many clients use telehealth as their primary means of receiving treatment

What is the maintenance role in group therapy?

· Help maintain purpose & process of the group (ex. Harmonizer attempts to prevent conflict)

What is the task role in group therapy?

· Take on various tasks, such as being the recorder of sessions

What is the individual role in group therapy?

· Tend to prevent teamwork b/c individuals take on roles to promote their own agenda (ex. Dominator trying to control other members)

Blaming in dysfunctional families

Members blame others to shift focus away from themselves

Manipulating in dysfunctional families

Members use dishonesty to support their own agendas

Placating in dysfunctional families

One member takes responsibility for problems to keep peace at all costs

Distracting in dysfunctional families

A member inserts irrelevant information during attempts at problem-solving

Generalizing in dysfunctional families

Members use overall descriptions (always, never) in describing encounters

Scapegoating

A member of the family with little power is blamed for problems within the family

Triangulation

A third party is drawn into the relationship with two members whose relationship is unstable

What is schizophrenia?

Psychotic thinking for at least 6 months. Areas of functioning are significantly impaired.

- Affects how people perceive reality, think, and act socially

What is schizoaffective disorder?

The client's disorder meets the criteria for both schizophrenia & depressive or bipolar disorder

What is psychosis?

A state in which a person experiences hallucinations, delusions, or disorganized thoughts, speech, or behavior

What is a brief psychotic episode?

The client has positive & negative symptoms lasting 1-30 days (max.)

Clients can experience psychosis in which other mental health disorders besides schizophrenia?

Bipolar disorder & major depressive disorder

What is substance-induced schizophrenia disorder?

Client experiences psychosis due to substance intoxication or withdrawal

What are the positive symptoms of schizophrenia?

· Hallucinations (auditory)

· Delusions

· Alterations in speech

· Bizarre behavior

Command = Most Danger

What are the negative symptoms of schizophrenia? 5 A's

· Affect

· Alogia

· Anergia

· Anhedonia

· Avolition

Affect

Usually blunted or flat expressions

Alogia

Poverty of thought or speech. Might mumble or respond vaguely

Anergia

Lack of energy

Anhedonia

Lack of pleasure or joy

the patient is indifferent

Avolition

Lack of motivation in activities & hygiene

Ideas of reference delusion

Believing others are talking about them

Persecution delusion

belief that others are out to get them, hunted by the FBI

Grandeur delusion

Believes they are like a God

Thought broadcasting delusion

Believes their thoughts are being heard by others

Thought withdrawal delusion

Believes that their thoughts have been removed from their mind by an outside agency

Thought insertion delusion

Believes the others' thoughts are being inserted into their mind

Religiosity delusion

Obsesses with religious beliefs

Magical thinking

Believes their actions or thoughts are able to control a situation or affect others

What is the most dangerous type of hallucination and how would you ask the client about this?

Command hallucinations: "are the voices telling you to do this?"

Gustatory hallucinations

Experiencing tastes

Tactile hallucinations

Feeling bodily sensations

Associative looseness (flight of ideas) alterations in speech

Client may say sentence after sentence but each may relate to a different topic and the listener is unable to follow the clients thoughts

Neologisms alterations in speech

Made-up words that have meaning only to client

Echolalia alterations in speech

The client repeats words spoken to them

Clang association alterations in speech

Meaningless rhyming words - fox, box, lox

Word salad alterations in speech

Words jumbled together with little meaning

Waxy flexibility alterations in behavior

Maintaining a specific position for an extended period of time (acute)

Echopraxia alterations in behavior

Purposeful imitation of movements made by others (child copying hand movements of mother)

Catatonia alterations in behavior

Pronounced decrease or increase in the amount of movement

First-generation antipsychotic medication treats which type of schizophrenia symptoms?

Only positive symptoms

Therapeutic uses for 1st generation (conventional) antipsychotic medications?

· Tx of acute & chronic psychotic disorder

· Prevention of N/V through blocking of dopamine in the chemoreceptor trigger zone of medulla

What are the first-generation (conventional) antipsychotic medications?

· Haloperidol

· Chlorpromazine

· Fluphenazine

· Thiothixene

· Thioridazine

What are the S/E for first-generation antipsychotic medications?

· Agranulocytosis(drop in WBC)

· Anticholinergic effects

· EPS (higher risk)

· Neuroleptic malignant syndrome

· Tardive dyskinesia(involuntary movements)

- orthostatic hypotension

- skin effects (photosensitivity)

· Sedation

Contraindications for 1st generation (conventional)?

Severe depression, severe HTN, prolactin-dependent breast cancer

Precautions for 1st generation (conventional)?

Use cautiously in glaucoma, paralytic ileus, prostate enlargement, heart, liver, kidney, or seizure disorders

2nd & 3rd generation (atypical) is a pregnancy category risk ___?

C

Second-generation antipsychotic medication treats which type of schizophrenia symptoms?

Positive & negative symptoms; works mainly by blocking serotonin

2nd & 3rd generation (atypical) Adverse effects

· New-onset Diabetes mellitus (metabolic syndrome)

· Loss of glucose control with DM (metabolic syndrome)

· Weight gain

· Hypercholesterolemia

- anticholinergic effects

· sexual dysfunction (low libido)

Clients taking Asenapine (2nd generation) should avoid eating or drinking for how long after each dose?

10 min.

What are the second-generation (atypical) antipsychotic medications?

· Olanzapine (Zyprexa)

- Risperidone (Risperdal)

· Clozapine (Clozaril)

· Asenapine

“ORCA”

Precautions for 2nd & 3rd generation (atypical)?

Use cautiously with cardiovascular, cerebrovascular, diabetes mellitus or seizures

Therapeutic uses for 2nd generation (conventional) antipsychotic medications?

· Schizophrenia

· Management of Sx of psychotic disorders

· Acute mania associated with bipolar disorder

Which class of antipsychotic medications are contraindicated in older adults who have dementia?

All (1st, 2nd, & 3rd)

Olanzapine (Zyprexa) nursing considerations

· Smoking decreases effectiveness

· Comes in short & long acting IM injection

Risperidone nursing considerations

· Lower risk of EPS but increased risk for hyperglycemia, metabolic syndrome, orthostatic hypotension

· Monitor for malignant syndrome

· Comes in long-acting IM injection given every 2-4 weeks