NSG 312: Mental Health and Safety/Risk Assessments

not the WHO 💔, also watch videos embedded in powerpoint, couldnt watch in class

WHO

World Health Organization

The WHO says this about mental health:

“there is no health without mental health . . . it [is a] state of well-being in which the individual realizes their own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to their community.”

Mental health is:

the foundation for wellbeing and effective functioning for an individual and for a community

Common mental health disorders

anxiety/depressopn, substance abuse

Mental health nursing assessment screens for?

preexisting, current conditions (there are ones for all age groups)

Safety assessment comes in?

many forms; has unique risk factors and characteristics

Mental health assessment is based on?

patient observation; patient responses

Mental health assessment is integral to?

any full medical or nursing examination

Mental health assessment must be inferred from?

from answers to questions, behaviors (cannot always be directly observed)

Subjective Data includes:

~statements to the nurse

~overheard patient reporting (to someone else)

~family and friends’ report, validation of patient’s data

You should ask _____-ended questions.

open

Assessment is an ___ as well as a science.

art

With a mental health assessment you are assimilating both _______ and _________ data.

verbal, nonverbal

What should you establish first when conducting an asssessment?

rapport

What should you be aware of when asking questions?

patient divergent strategies

Objective date

observing patient, patient’s behavior

Physical presentation may be the _____ indication

first

ex: toxicity; underlying medical problem, psychosis

Data organization (ABCT) plus MMSE

Appearance: overall; posture; movement; hygiene, grooming; dress

Behavior: level of consciousness; eye contact, facial expressions; speech

Cognitive function: orientation; attention span; memory; judgment

Thought processes and perceptions: MMSE/Mini-Cog.

Mini-mental state examination

Unchangeable factors

family history, age, gender

Environmental (changeable) factors

support systems, housing, health care accessibility, literacy

Metabolic issues/associated physiological processes

parkinson disease; cancer; HIV/AIDS; other chronic conditions

Identification of risks identifies?

health promotion teaching topics

History and Risk Factors:

Personal history

Psychosocial history

- support network

- substance use

- spirituality

Medications

Family history

Common symptoms of altered mental health:

suicidal ideation, homicide ideation and aggressive behavior, mood and affect incongruent with …, symptoms of psychosis (hallucinations, delusions, dissociative symptoms)

What is asked first with Rsk Screening Questions?

safety, harm to others

Situation includes risk for injury due to?

~psychotic states; depression

~dementia; delirium

Why do you ask safety questions first?

prevents forgetting to ask about safety and allows more time to focus on presenting situation

Approximately ____ of women are victims worldwide. (often goes unreported)

1/3

Family Violence involves?

child maltreatment, trauma symptoms, sibling violence, intimate partner violence (IPV), elder abuse

Trauma symptoms

anxiety; depression; anger; aggression

Sibling Violence

rivalry, roughhousing, competition

IPV

intimate partner violence

Elder Abuse

abuse; neglect; financial exploitation; abandonment

Violence against adults with disabilities:

intentional/unintentional abuse/neglect: physical; sexual; psychological; financial

Youth and school violence:

bullying, verbal and physical violence; humiliation and shaming; in public or with an audience

Sexual violence:

forced sex in dating, marital relationships, gang rape; sexual harassment; molestation, inappropriate touching; sex with a patient, forced prostitution; forced exposure to sexually explicit behavior

Hate crimes

perpetrator chooses a victim because of a characteristic, provides evidence that hate motivated the crime.

(race; ethnicity; gender; sexuality; religion)

Human trafficking

recruitment, transportation, transfer, harboring, or receipt of people through threats, force, coercion, or deception for indentured servitude

Patient interviews

~paramount: patient physical, emotional safety

~completed in private: Patient data is confidential.

~listen > talk: (80% patient, 20% nurse)

~generalized strategies

~preface sensitive questions to prepare patient.

~assess daily routine; include questions about adverse childhood, family event

Parts of mental health assessment:

~objective findings R/T patients victimized by violence

~nonverbal behaviors: possible abuse, neglect

~”Red flags”

*Documentation

Violence victims’ common symptoms during assessment:

~easily triggered: anxiety, panic episodes

~isolation, social withdrawal; difficulty focusing

~numbing/shutting down feelings

~spacing out; forgetfulness

Madated Reporting is required when?

child, elder, vulnerable-adult abuse or neglect is disclosed, assessed, or suspected

Mandated reporters

nurses, health care professionals, etc.

Mandated reporting involves calling?

protective services hotline

Mandated reporter is protected by the state if?

report is made in good faith, without malice

When calling the protective services hotline you should?

document; eeason for call; time of call; full name of who took call; response of call taker

North Carolina G.S. §7B-301, Duty to Report

• Anyone who suspects child abuse, neglect, or dependency must report their concerns

• Reports must be made to the county DSS where the juvenile resides or is found

• May be made orally, by telephone or in writing

• Reporter must give their name, address and telephone number

• Class 1 misdemeanor for knowingly or wantonly failing to report

Critical Thinking regarding Mental Health Assessment:

Nursing diagnoses

Patient outcomes (partial list)

- patient: does not harm self; demonstrates appropriate social interaction; identifies person strengths

Nursing interventions (partial list)

- assess for risk of harm to self, others.

- provide safe environment by removing items which may cause harm.

- identify support systems, involve them in care.