Mental Health - Exam 2

evidence-based practice (EBP)

Integrate best current evidence with clinical expertise and patient/family preferences and values for delivery of optimal healthcare.

health teaching

adaptive to the patient’s special needs (age, culture, ability to learn, readiness) and recovery goals.

mental status examination (MSE)

Appearance

• Grooming and dress

• Level of hygiene

• Pupil dilation or constriction

• Facial expression

• Height, weight, nutritional status

• Presence of body piercing or tattoos, scars, etc.

• Relationship between appearance and age

Behavior

• Excessive or reduced body movements

• Peculiar body movements (e.g., scanning of the environment, odd or repetitive gestures, level of consciousness, balance, and gait)

• Abnormal movements (e.g., tardive dyskinesia, tremors)

• Level of eye contact (keep cultural differences in mind)

Speech

• Rate: slow, rapid, normal

• Volume: loud, soft, normal

• Disturbances (e.g., articulation problems, slurring, stuttering, mumbling)

Mood

• Affect: flat, bland, animated, angry, withdrawn, appropriate to context

• Mood: sad, labile, euphoria

• Disorders of the Form of Thought

• Thought process (e.g., disorganized, coherent, flight of ideas, neologisms, thought blocking, circumstantiality)

• Thought content (e.g., delusions, obsessions)

Perceptual Disturbances

• Hallucinations (e.g., auditory, visual)

• Illusions

Cognition

• Orientation: time, place, person

• Level of consciousness (e.g., alert, confused, clouded, stuporous, unconscious, comatose)

• Memory: remote, recent, immediate

• Fund of knowledge

• Attention: performance on serial sevens, digit span tests

• Abstraction: performance on tests involving similarities, proverbs

• Insight

• Judgment

Ideas of Harming Self or Others

• Suicidal or homicidal history and current thoughts

• Presence of a plan

• Means to carry out the plan

• Opportunity to carry out the plan

milieu therapy

a psychiatric philosophy that involves a secure environment including people, settings, structure, and emotional climate to effect positive change. Milieu therapy takes naturally occurring events in the environment and uses them as rich learning opportunities for patients. A consistent routine and structure is maintained to provide predictability and trust.

Nursing Interventions Classification (NIC)

is a research-based, standardized listing of interventions. These interventions are linked to NOC outcomes and represent the third level in unifying the nursing process through NANDA-I, NOC, and NIC.

Nursing Outcomes Classification (NOC)

a standardized list of nursing outcomes in Nursing Outcomes Classification (NOC). Outcomes for each NANDA-I diagnosis are included. NOC gives us a way to evaluate the effect of nursing interventions. Each outcome has an associated group of indicators used to determine patient status in relation to the outcome.

objective data

Usually seen in MSE

refers to all things that nurses observe about the patient with five senses. The nurse observes the patient’s physical behavior, nonverbal communication, appearance, speech patterns, mood and affect, thought content, perceptions, cognitive ability, and insight and judgment. Objective data also includes all measurable information such as body weight, blood pressure, and oxygen saturation

subjective data

Usually discussed in psychosocial assessment

refers to all information that you gather from a patient and from people who may accompany the patient. The focus of the history is the patient’s perceptions and recollections of current lifestyle and life in general. Support, such as family and friends, education, work experience, coping styles, and spiritual and cultural beliefs, is typically discussed during a psychosocial history.

outcome criteria

These are the hoped-for outcomes that reflect the maximum level of patient health that the patient can realistically achieve through nursing interventions.

• Goal outcomes reflect maximal patient health that can be realistically achieved through evidence-based interventions

• Provide direction for continuity of care

• Patient-centered and culturally appropriate

psychosocial assessment

additional information from which to develop a plan of care. This type of assessment always begins by asking the patient to describe how treatment became necessary. This is known as the chief complaint and should be documented verbatim, that is, in the patient’s own words.

Basic psychosocial assessment: hospitalizations, education, employment, social patterns, sexual patterns, interests/abilities, substance use, coping abilities, spirituality

• Previous hospitalizations

• Educational background

• Occupational background

  • Employed? Where? What length of time

  • Special skills

• Social patterns

  • Describe family.

  • Describe friends. With whom does the patient live?

  • To whom does the patient go in time of crisis?

  • Describe a typical day.

• Sexual patterns

  • Sexually active? Practices safe sex? Practices birth control?

  • Sexual orientation

  • Sexual difficulties

• Interests and abilities

  • What does the patient do in his or her spare time?

  • What sport, hobby, or leisure activity is the patient good at?

  • What gives the patient pleasure?

• Substance use and abuse

  • What medications does the patient take? How often? How much?

  • What herbal or over-the-counter drugs does the patient take (caffeine, cough medicines, St. John’s wort)? How often? How much?

  • What psychotropic drugs does the patient take? How often? How much?

  • How many drinks of alcohol does the patient take per day? Per week?

  • What recreational drugs does the patient use (club drugs, marijuana, psychedelics, steroids)?

    • How often? How much?

    • Does the patient overuse prescription drugs (benzodiazepines, pain medications)?

    • Does the patient identify the use of drugs as a problem?

• Coping abilities

  • What does the patient do when he or she gets upset?

  • To whom can the patient talk?

  • What usually helps relieve stress?

  • What did the patient try this time?

• Spiritual assessment

  • What importance does religion or spirituality have in the patient’s life?

  • Do the patient’s religious or spiritual beliefs relate to self-care practices? How?

  • Does the patient’s faith help the patient in stressful situations?

  • Whom does the patient see when he or she is medically ill? Mentally upset?

  • Are there special healthcare practices within the patient’s culture that address his or her particular mental problem?

HEADSSS assessment

HEADSSS: good for adolescents

• H Home environment (e.g., relations with parents and siblings)

• E Education and employment (e.g., school performance)

• A Activities (e.g., sports participation, after-school activities, peer relations)

• D Drug, alcohol, or tobacco use

• S Sexuality (e.g., whether the patient is sexually active, practices safe sex, or uses contraception)

• S Suicide risk or symptoms of depression or other mental disorder

• S Safety (e.g., how safe does the patient feel at home and school, wear a safety belt, or engage in dangerous or risky activities)

What should interventions look like/Planning

• Safe: Interventions must be safe for the patient, as well as for other patients, staff, and family.

• Compatible and appropriate: Interventions must be compatible with other therapies and with the patient’s personal goals and cultural values, as well as with institutional rules.

• Realistic and individualized: Interventions should be (1) within the patient’s capabilities, given the patient’s age, physical strength, condition, and willingness to change; (2) based on the number of staff available; (3) reflective of the actual available community resources; and (4)within the student’s or nurse’s capabilities.

• Evidence-based: Interventions should be based on scientific evidence and principles when available.

the nursing process

Assessment, diagnosis, outcome identification, planning, implementation, evaluation

Assessment

• The psychiatric mental health registered nurse collects and synthesizes comprehensive health data that are pertinent to the health care consumer’s health and/or situation.”

• Use holistic, evidence-based assessment technique

• Primary source = patient; secondary sources (others)

• Health Insurance Portability and Accountability Act (HIPAA)

• Document relevant data in retrievable format

• Assessment considerations: Age, Language barriers

• Goal: rapport, chief complaint, risks, baseline (MSE/psychosocial), goals of tx, needs/conditions

Diagnosis

formulate nursing diagnosis

• Types:

  • Problem: ex. anxiety

  • health promotion: willingness to enhance specific health behaviors

  • Risk: High probability of a future negative event for a vulnerable individual

• related factors: anxiety related to homelessness

• Defining characteristic: depression evidence by crying

outcome identification

The psychiatric mental health registered nurse identifies expected outcomes and the health care consumer’s goals were planned individualized to the health care consumer or to the situation

SMART: specific, measurable, relevant/realistic, time based

Planning

The psychiatric–mental health registered nurse develops a plan that prescribes strategies and alternatives to assist the health care consumer in achieving expected outcomes.

Specific principles: (1) Safe (2) Evidence-based whenever possible (3) Realistic (4) Compatible with other therapies

Care plans should be: safe, appropriate, individualized, and evidence-based

Implementation

“The psychiatric–mental health registered nurse implements the identified plan.”

Basic Level: PMH-RN Role

• Standard 5A-Coordination of Care

• Standard 5B-Health Teaching and Health Promotion

• Standard 5E-Phamacological, Biological, and Integrative Therapies

• Standard 5F- Milieu therapy

• Standard 5G-Therapeutic relationship and counseling

Advanced Practice Level: PMH-APRN Role

• Prescriptive Authority and Treatment

• Psychotherapy

• Consultation

Evaluation

The psychiatric–mental health registered nurse enhances progress toward attainment of expected outcomes.

Systematic, ongoing, criterion-base, Include supporting data, Enables revisions to diagnoses, outcomes, and interventions

Goals may be met, partially met, not met

Documentation

Contents

• Evaluation of stated outcomes

• All changes in patient condition

• Record of informed consents

• Medication reactions

• Symptoms/concerns

• Untoward incidents

• Patient progress

• Nonadherence