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What does a mental health assessment consist of?
· Physical assessment
· Psychosocial history
· Mental status exam
· Screening tools
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
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
Veracity
Honesty
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 Tx
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, 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
What is an example of false imprisonment?
Confining a patient to a seclusion room
What is an example of assault?
Making a threat to a client
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
· Better decision-making strategies to help live productive lives, develop strong sense of self
Focus & goals for group therapy?
· Help develop healthy relationships within a group setting
· 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
· 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
· Delusions
· Alterations in speech
· Bizarre behavior
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
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
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)
· 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 DM
· Loss of glucose control with DM
· Weight gain
· Hypercholesterolemia
· sexual dysfunction
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?
· Risperidone (Risperdal)
· Olanzapine (Zyprexa)
· Clozapine (Clozaril)
· Asenapine
Precautions for 2nd & 3rd generation (atypical)?
Use cautiously with cardiovascular, cerebrovascular, 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