NUR 330 Mental Health Week 3/Module 2

psychiatric nursing process assessment definition

The deliberate and systematic collection and interpretation of biopsychosocial information or data to determine current and past health, functional status, and mental health problems, both actual and potential

assessment framework

major reason for seeking help

initial patient information (name, age, marital status, gender, ethnic background, etc)

past and present health status

What’s included in a patients health status

physical functions (elimination, exercise, sleep, appetite/nutrition, hydration, sexuality, self-care, existing physical illnesses)

medications (prescription, OTC, supplements, dosages, side effects, frequency)

lab tests (significant lab results and normal ranges)

PMH/physical/biologic conditions assessed in biologic assessment

• Previous medical conditions

• Hospitalizations

• Surgical procedures

• Vision/hearing problems

• Cardiac problems

• Respiratory problems

• Neurologic problems

• Endocrine disorders

• Immune disorders

• Substance use/exposure

• Abuse/dependence

• Herbal preparations

Appetite and nutrition changes

appetite

nutritional intake

eating patterns

self-care changes

grooming

dressing

washing

CBC relevance

complete blood count- psych meds can affect blood cells

findings like:

leukopenia

agranulocytosis

leukocytosis

anemia

hyponatremia

low serum sodium

significant mental status changes

hypokalemia

low serum potassium

common in bulimic behavior, psychogenic vomiting, use or abuse of diuretics, laxative abuse

weakness, fatigue, ECG changes, paralytic ileus, muscle paresis

bicarbonate elevated

binging and purging in eating disorders

excessive use of laxatives

psychogenic vomiting

chloride decreased

binging-purging behavior, repeated vomiting

elevated BUN (blood urea nitrogen)

associated with mental status changes

lethargy

delirium

may be caused by dehydration

elevated creatinine

level not typically elevated until approx. 50% of nephrons in kidneys are damaged

elevated amylase

increased after binging and purging, declines when stopped

elevated creatine phospho-kinase (CPK)

repeated IM injections

elevated T₃

hyperthyroidism, may produce mood changes, anxiety, symptoms of mania

elevated TSH

hypothyroidism- depression-like symptoms with physical signs of cold intolerance, dry skin, hair loss, bradycardia

LITHIUM TOO

pharmacologic assessment

• What medications the patient currently takes

• What medications the patient has taken previously

• Why medications were prescribed

• How the patient responded

• Whether side effects occurred

• Whether medications may be contributing to current symptoms

Emphasize what pt has taken in the past vs. currently taken to possibly identify meds that may cause psych symptoms

Mental status examination (MSE)

general observations

orientation

mood, affect, emotions

speech

thought processes

cognition and intellectual performance

general observations (MSE)

appearance

affect

psychomotor activity

overall behavior

orientation (MSE)

person, place, time

What is todays date? What day of the week is it?

Where are we?

What’s your name?

mood and affect (MSE)

mood- sustained, overall emotions expressed or exhibited

affect- capacity to vary outward emotional expression, observed in facial expressions, vocal fluctuations, gestures

euthymic

normal mood

euphoric

elated mood

labile

changeable mood

dysphoric

depressed, disquieted, restless mood

speech (MSE)

pressured, fast, slow, fragmented

repetition or rhyming?

thought process (MSE)

rapid change of ideas

inability or taking long to get to the point

loose or no connections between ideas

cognition and intellectual performance components (MSE)

1) attention and concentration

2) abstract reasoning and comprehension

3) memory

4) insight and judgment

attention and concentration (MSE)

“start with 100 and subtract 7 until you get to 65”

“start with 20 and subtract 3”

spell “world” backwards

abstract reasoning and comprehension (MSE)

give a saying and ask to interpret

“don’t cry over spilled milk”

memory (MSE)

immediate and short-term: give 3 words

recent: ask about holiday or recent event within past few months

remote or long-term: events years ago

insight and judgment (MSE)

insight- awareness of own thoughts and feelings

judgment- ability to reach a logical decision about a situation and choose a course of action

self-concept components

body image

self-esteem

personal identity

suicidal ideation

have you ever thought about injuring or killing yourself?

attempts

plan

means to do so

preparations

homicidal ideation

have you ever thought about harming someone?

intent

plan

means

functional status

career

job

home

psychiatric nursing diagnosis

A clinical judgment about an identified problem or need that requires nursing interventions and nursing management

restating

clarify what the patient is trying to say by restating it

reflecting

present the last statement as a question, giving them a change to expand on information

pharmacodynamics

what the drug does to the body

pharmacokinetics

what the body does to the drug

absorption

distribution

metabolism

elimination

Norepinephrine reuptake inhibitor effects

• Antidepressant action

• Potentiation of pressor effects

Norepinephrine reuptake inhibitor side effects

• Tachycardia

• Tremors

• Insomnia

• Erectile/ejaculatory dysfunction

Norepinephrine reuptake inhibitor examples

• Desipramine (norpramin)

• Venlafaxine (effexor)

Serotonin reuptake inhibitor (SSRI) effects

• Antidepressant action

• Anti-obsessional effect

Serotonin reuptake inhibitor (SSRI) side effects

• Increased/decreased anxiety depending on dose

• GI distress

• Nausea

• Headache

• Nervousness

• Motor restlessness

• Sexual side effects

Serotonin reuptake inhibitor (SSRI) examples

Fluoxetine

Fluvoxamine (luvox)

Dopamine reuptake inhibitor (NDRI) effects

• Antidepressant action

• Antiparkinsonian effect

Dopamine reuptake inhibitor (NDRI) side effects

• Increased psychomotor activity

• Aggravation of psychosis

Dopamine reuptake inhibitor (NDRI) examples

buproprion

Histamine H1 receptor blockade associated effects

• Sedation

• Drowsiness

• Hypotension

• Weight gain

Histamine H1 receptor blockade examples

• Quetiapine

• Imipramine

• Clozapine

• Olanzapine

Muscarinic/acetylcholine receptor blockade effect

anticholinergic:

• Dry mouth

• Blurred vision

• Constipation

• Urinary hesitancy/retention

• Memory dysfunction

• Sinus tachycardia

Muscarinic/acetylcholine receptor blockade examples

• Imipramine

• Amitriptyline

• Thioridazine

• Clozapine

Alpha-1 receptor blockade side effects

• Postural hypotension

• Dizziness

• Reflex tachycardia

• Sedation

SSRIs

• Fluoxetine

• Sertraline

• Paroxetine

• Citalopram

• Escitalopram

SNRIs

• Venlafaxine

• Duloxetine

• Desvenlafaxine

TCAs

• Amitriptyline

• Imipramine

• Nortriptyline

prior to electroconvulsive therapy (ECT)

• Obtain informed consent

• Provide education

• NPO after midnight

• Obtain required laboratory tests

• ECG

• Physical evaluation

• Remove dentures

• Remove loose objects

• Establish IV

• Oxygen available

monitor after ECT

• Vital signs

• Confusion

• Orientation

• Recovery

provide after ECT

• Reorientation

• Assistance with ambulation

• Supervision

• Follow-up

• Memory aids

psychotherapy groups

treat individuals' emotional problems and can be implemented from several theoretical perspectives, including:

• Psychodynamic

• Behavioral

• Cognitive

The focus is on:

• Examining emotions and perspectives

• Helping individuals face their life situations

• Examining and resolving psychological and interpersonal issues within a safe environment

psychoeducation groups

Psychoeducation groups are designed to:

• Enhance knowledge

• Improve skills

• Help patients solve problems

The group uses educational strategies to help patients learn information and skills.

What happens in the group?

The group leader:

• Develops a lesson plan for each session

• Includes objectives

• Provides content

• Uses references

• Uses evaluation tools

Groups are usually time-limited and may be especially useful for health-maintenance behaviors such as exercise and weight control.

Psychoeducation = teaching patients knowledge and skills.

supportive therapy groups

Supportive therapy groups are generally less intense than psychotherapy groups.

Their focus is helping individuals:

• Cope with illnesses

• Cope with problems

• Help each other through situations common to other group members

Example from the textbook

A group of patients with stable bipolar illness may meet to discuss:

• Their illness

• How to cope with it

• How to cope with a family member who seems insensitive to the illness

Family caregivers can also benefit from support and information about providing care.

Self-help groups

Self-help groups are led by people who are concerned about coping with a specific problem or life crisis.

Important:

These groups do NOT explore psychodynamic issues in depth.

Professionals generally:

• Do not attend these groups

• Do not serve as consultants

Examples

• Alcoholics Anonymous

• Overeaters Anonymous

• One Day at a Time (grief group)