Topic 1: Ch 7 Nursing Process and Standards of Care

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47 Terms

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  • mental status exam (MSE)

  • psychosocial assessment

  • physical examination

  • history taking

  • interviews

  • standardized rating scales

what does assessment of the BH client include

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  • Home environment: relations with parents and siblings

  • Education and employment: school performance

  • Activities: sports, after-school activities, peer relations

  • Drug, alcohol, or tobacco use

  • Sexuality: sexually active, practices safe sex, uses contraception

  • Suicide risk or symptoms of depression/other mental disorder

  • Safety: how safe the patients feels at home/school, wear a safety belt, engage in dangerous/risky activities

what is the HEADSSS Psychosocial Interview technique

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  • establish rapport

  • obtain an understanding of the current problem/chief complaint

  • review the patient’s physical status/obtain baseline VS

  • assess for RF affecting the safety of the paitent/others

  • Perform a MSE

  • assess psychosocial status

  • identify mutual goals for treatment

  • formulate a plan of care

  • document data in a retrievable format

what is the purpose of the psychiatric mental health nursing assessment

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mental status exam (MSE)

aids in collecting objective information and is fundamental to the psychiatric-mental health nursing assessment

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psychosocial assessment

provides additional information from which to develop a plan of care that begins with asking the patient to describe how treatment became necessary

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  • stroke

  • Alzheimer’s

  • Brain tumor

  • Huntington’s

  • Epilepsy

  • MS

  • Parkinson’s

which neurological disorders are associated with depression

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  • Mononucleosis

  • Encephalitis

  • Neurosyphilis

  • HIV

which infections are associated with depression

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  • hypo/hyperthyroidism

  • Cushing’s

  • Addison’s

  • Parathyroid disease

which endocrine disorders are associated with depression

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  • liver cirrhosis

  • pancreatitis

which GI disorders are associated with depression

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  • hypoxia

  • CHF

which CV disorders are associated with depression

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  • sleep apnea

which respiratory disorders are associated with depression

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  • thiamine

  • protein

  • B12

  • B6

  • Folate

what nutritional deficiencies are associated with depression

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  • lupus

  • rheumatoid arthritis

what collagen vascular disorders are associated with depression

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  • Alzheimer’s

  • Brain tumor

  • Stroke

  • Huntington’s

which neurological disorders are associated with anxiety

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  • encephalitis

  • meningitis

  • neurosyphilis

  • septicemia

which infections are associated with anxiety

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  • hypo/hyperthyroidism

  • hypoparathyroidism

  • hypoglycemia

  • pheochromocytoma

  • carcinoid

which endocrine disorders are associated with anxiety

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  • low calcium

  • low potassium

  • acute intermittent porphyria

  • liver failure

which metabolic disorders are associated with anxiety

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  • angina

  • CHF

  • pulmonary embolus

which CV disorders are associated with anxiety

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  • pneumothorax

  • acute asthma

  • emphysema

which respiratory disorders are associated with anxiety

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  • stimulants

  • sedatives (withdrawal)

  • lead, mercury poisoning

which drug effects are associated with anxiety

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  • temporal lobe epilepsy

  • migraines

  • temporal arteritis

  • occipital tumors

  • narcolepsy

  • encephalitis

  • hypothyroidism

  • Addison’s

  • HIV

which medical conditions are associated with psychosis

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  • hallucinogens (LSD)

  • phencyclidine

  • alcohol withdrawal

  • stimulants

  • cocaine

  • corticosteroids

which drug effects are associated with psychosis

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  • grooming/dress

  • levels of hygiene

  • pupil dilation/constriction

  • facial expression

  • height, weight, nutritional status

  • presence of body piercing or tattoos, scars, etc

  • relationship between appearance and age

what should the nurse include when assessing appearance in a MSE

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  • excessive/reduced body movements

  • peculiar body movements (scanning of the room, odd/repetitive gestures, LOC, balance, gait)

  • abnormal movements (tardive dyskinesia, tremors)

  • level of eye contact (with cultural differences in mind)

what should the nurse include when assessing behavior in a MSE

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  • rate: slow, rapid, or normal

  • volume: loud, soft, or normal

  • disturbances: articulation problems, slurring, stuttering, mumbling

what should the nurse include when assessing speech in a MSE

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  • affect: flat, bland, animated, angry, withdrawn, appropriate to context

  • sade, labile, euphoric

what should the nurse include when assessing mood in a MSE

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  • thought process: disorganized, flight of ideas, neologisms, thought blocking, circumstantiality

  • thought content: delusions, obsessions

what should the nurse include when assessing disorders of the form of thought in a MSE

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  • hallucinations: auditory, visual

  • illusion

what should the nurse include when assessing perceptual disturbances in a MSE

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  • orientation: time, place, and person

  • LOC: alert, confusion, clouded, stuporous, unconscious, comatose

  • memory: remote, recent, immediate

  • fund of knowledge

  • attention: performance on serial sevens, digit span tests

  • abstraction: performance on tests involving similarities, proverbs

  • insight

  • judgement

what should the nurse include when assessing cognition in a MSE

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  • suicidal or homicidal history and current thoughts

  • presence of a plan

  • means to carry out the plan

  • opportunity to carry out the plan

what should the nurse include when assessing ideas of harming self/others in a MSE

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psychosocial assessment

includes:

  • previous hospitalizations

  • educational background

  • occupational background

    • employed, where, what length of time

    • special skills

  • social patterns

    • describe family friends, household members, support system, and a typical day

  • sexual patterns

    • sexually active, practices safe sex/birth control

    • sexual orientation

    • sexual difficulties

  • interests

    • how do you spend spare time

    • interest in sports, hobbies, or leisure activities

    • what gives patient pleasure

  • substance use

    • what prescribed medications, how often, how much

    • any herbal or OTC meds, how often, how much

    • how many alcoholic beverages and what time per day/week

    • what recreational drugs, how often, how much

    • misuse prescription durgs

    • use drugs as a problem

  • coping abilities

    • what to you do when upeset

    • who do you talk to

    • what helps relieve stress

  • spiritual assessment

  • health behaviors

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MDD

these standardized rating scales are used for what

  • Beck inventory

  • Brief PHQ

  • Geriatric Depression Scale (GDS)

  • Hamilton Depression Scale

  • Zung Self Report Inventory

  • PHQ-9

  • PHQ-A

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anxiety

these standardized rating scales are used for what

  • Brief PHQ

  • Generalized Anxiety Disorder-7 (GAD-7)

  • Modified Spielberger State Anxiety Scale

  • Hamilton Anxiety Scale

  • Severity Measure for Generalized Anxiety Disorder Child (11-17)

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trauma

  • adverse childhood experiences questionnaire

  • brief trauma questionnaire

  • PTSD Scale for SDM-5 (CAPS-5)

  • PTSD Symptom Scale Interview (PSS-I and PSS I-5)

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long term goals/outcomes for a suicidal patient

  • patient will remain free from injury throughout the hospital stay

  • by discharge, patient will express hope and a desire to live and identify at least two people to contact if suicidal thoughts arise

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short term goals/outcomes for a suicidal patient

  • patient will identify the rationale and procedure of the unit’s protocol for suicide precautions shortly after admission

  • patient will seek out staff when feeling overwhelmed or self-destructive duriing hospitalization

  • patients will meet with social worker to find supportive resources in the community before discharge and work on trigger issues

  • by discharge, patient will state the purpose of medication, time and dose, adverse effects, and whom to call for questions or concerns

  • patient will have the written anem and telephone numbers of at least two people to turn to if feeling overwhelmed or self destructive

  • patient will have a follow up appointment to meet with a mental health professional by discharge

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a, e

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c

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a, b, d, e

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c

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d

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d

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b

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a

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b

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a, b, d