Chapter 9 Heath assessment

Nurse's Role in Mental Health

Identify mental health risk factors, intervene in cases of violence or substance use, and promote prevention and awareness strategies.

Family Violence

Includes physical, sexual, or emotional abuse among related individuals such as spouses, children, siblings, or elders.

Sexual Violence

Non-consensual sexual acts like rape, harassment, molestation, and trafficking; varies in cultural perception.

Human Trafficking

Form of modern slavery involving sexual exploitation, forced labor, or marriage; includes child trafficking.

Signs of Child Abuse

May include behavioral signs like anxiety, depression, aggression, or withdrawal from normal activities.

Elder Abuse

Harm caused intentionally or unintentionally by caregivers; includes neglect, financial abuse, or abandonment.

Hate Crimes

Acts of violence driven by bias against race, religion, gender, sexual orientation, or disability; cause emotional trauma.

Substance Misuse

The improper use of legal or illegal drugs, including overuse, mixing, or using without prescription.

Addiction

A chronic condition characterized by compulsive drug seeking and use despite harmful consequences.

Alcohol Use Disorder

Medical condition involving uncontrolled alcohol use; can be mild, moderate, or severe with both physical and psychological effects.

CIWA Tool

Clinical Institute Withdrawal Assessment for Alcohol; used to assess and manage alcohol withdrawal symptoms.

Naloxone

Life-saving medication used to reverse the effects of opioid overdose (e.g., heroin, fentanyl).

Urgent Mental Health Assessment

Quick evaluation to determine if a patient is a danger to themselves or others; focuses on suicidal or homicidal thoughts.

Subjective Data

Information gathered from what the patient or family says, including emotions, behaviors, and statements.

Violence Interview Rule

Always conduct interviews about violence privately to ensure the patient feels safe to speak honestly.

Mandated Reporting

Legal obligation for nurses to report suspected abuse of children, elders, or vulnerable adults to protective services.

CAGE Assessment

A screening tool with four questions to identify potential alcohol dependence or abuse.

Mental Illness Risk Factors

Include personal or family history, substance use, exposure to violence, and current medications.

SAD PERSONAS Tool

Screening scale used to assess suicide risk based on factors like mood, age, support system, and substance use.

Mini-Cog

Test combining memory recall and clock-drawing to assess cognitive function, often used for dementia screening.

Dementia

a gradual, progressive decline in memory and thinking that interferes with daily life; Alzheimer's is the most common type.

Depression

a mood disorder with persistent sadness, lack of interest, and possible physical symptoms like fatigue or sleep problems.

Delirium

a sudden, temporary change in mental status causing confusion, disorientation, and trouble focusing; often caused by illness, medications, or infection.

Dementia onset

a slow and gradual onset, developing over months to years.

Depression onset

Can have a gradual or sudden onset, often triggered by life events or stress.

Delirium onset

a sudden and rapid onset, usually over hours to a few days.