Week 14 pain, mental health, substance abuse, interpersonal violence

determinants of mental health

genetics

poverty

violence

inequality

environmental deprivation

role of nurse in mental health assessment

be aware of bias

establish safe ans trusting environemnt for you and pt

allow sufficient time to assess

safety pauses and personel back up my be warranted

utilize appropriate screening tools

Assessing anxiety

GAD-7 screening

assess for:

restlessness of feeling keyed up/on edge

easily fatigued

difficulty concentrating/mind goes blank

irritability

muscle tension

sleep problems or disturbances

mild, moderate, severe panic

Depression screening

PHQ-9 scale

chemical imbalance in the brain - from trauma, genetics, prolonged stress

types:

Major__ disorder

persistent __ disorder

postpartum__ disorder

psychotic__

seasonal affective disorder

bipolar disorder

suicide risk assessment

all pts need this screeining type upon admission

use CSSR-S (columbia ___ severity rating scale

interpersonal violence - the nurses role

evaluate individuals at high risk and in vulnerable status

women

older adults

children

pregnant

immigrants

LGBTQIA

mandatory reporters - elder abuse, child abuse, abuse of person w/ diabilities and sexual absue

identify human trafficking

unable to givew answer about living or work conditions

inconsistent in answers during health history of home life

appears fearful, jumpy, anxious especially discussing law enforcement

signs of abuse, trauma, poor hygiene, malnourishment that is unexplained

SO refuses to leave patient alone

de-escalation measures

aware of surroundings

ensure safe exit available

dont treat pt alone

ensure team members aware of concerns

dont engage in arguments or challenge pts. or partner/family members

engage supportive comms, be concise, demonstrate open body language and calm demeanor

DONT attempt to stop pt from leaving

LAST - listen apologize solve and thank

screening for alcohol misuse, abuse or dependency

CAGE-0

felt the need to CUT down on ___

Annoyed by criticisms of you ___

felt GUILT for ____

ever felt you needed ___ first thing in the morning (EYE opener)

2 or greater cause for SBIRT

evaluation and management of alcohol withdrawl

CIWA - 10 item scale

score designed to prompt specific managemnt

benzos are first line therapy

res

MINI - mental state exam

used to assess cognitive status of older adults

not diagnostic - brief screenign for dementia, alzheimers

performed by trained clinician

scores interpretation needs to be adjusted based on pt education lvl

common causes of altered mental status - AEIOUTIPS

Alcohol

Epilepsey/electrolytes

Insulin

Opiate/oxygen

Uremia

Trauma/temperature

Infection

Poison/psychogenics

Shock, stroke

restraints

order is necessary to use, no longer than 1 hr before

orders include: justification, type, criteria for discontinuation

adults - renewel orders every 4hrs

child/adolescent - (9-17_) renew order every 2 hours

child (<9) renew orders ever hour

for violent patients - monitor every 15 minutes

restraint assessment

changes in a person orientation, attention span and memory

orientation - person place, time, location

memory

• immediate recall: able to recall 3 words immediately

• recent memory: can recall objs. after 10 minutes

• remote memory: can recall things from the past

calculation - simple math

assess judgement and reasoning

abstract reasoning - able to explain simple proverbs

Alzheimers dz

incurable, degenerative neurological disorder

most common cause of dementia in most western countries

3 stages: mild cognitive, early mid stage, late stage

Alzheimers dz - Mild cognitive impairment stage

2-4 yrs memory begins to fail

Alzheimers dz - early and mid stage dementia

2-12 yrs, progressive memory loss and difficulty w/ ADLs, dec in language, dioriented and confused, concentration issues

alzheimers dz - late stage

requires total care, unable to commmunication