MH1A PPT

Mental Health Nursing Assessment

Basic Concepts

  • Mental and behavioral health nursing encompasses:
    • Counseling.
    • Milieu therapy: Creating a safe, therapeutic environment with clear rules and boundaries.
    • Promotion of self-care activities: Providing support and rewards.
    • Psychobiological care: Medication administration, teaching, assessment for adverse drug effects, and evaluation.
    • Cognitive and behavioral therapy: Utilizing modeling, operant conditioning, and systematic desensitization.
    • Health teaching and promotion.
    • Case management.

Professional Standards

  • Standards are set by:
    • American Nurses Association.
    • American Psychiatric Nurses Association.
    • International Society of Psychiatric-Mental Health Nurses.

Methods and Principles

  • Nursing process.
  • Holistic nursing care.
  • Observation.
  • Interviewing.
  • Physical examination.
  • Collaborative care.

Assessment Components

  • Psychosocial assessment.
  • Mental Status Exam (MSE).
  • Standardized screening tools (when appropriate).
  • Lifespan considerations.
  • Focused physical assessment.
  • Establish rapport during the initial encounter.
  • Use therapeutic communication techniques (verbal and non-verbal).

Psychosocial Assessment

  • Cultural, religious, and spiritual considerations, including clergy support.
  • Support system.
  • Sleep patterns.
  • Depression and anxiety, including thoughts of suicide.
  • Coping mechanisms.
  • Alcohol, recreational drug, and tobacco use.
  • Patient’s understanding and perception of health, beliefs about the illness continuum.
  • Leisure, physical activity, and recreation.
  • Home medication adherence.
  • Use of vitamins, supplements, and OTC medications.
  • Feelings of safety at home.

Mental Status Examination (MSE)

  • Key areas:
    • LOC (Level of Consciousness), appearance, behavior, cognitive/intellectual functioning.
    • Level of orientation (person, place, time/situation).
    • Glasgow Coma Scale.
    • Levels of consciousness:
      • Alert: Spontaneously responsive.
      • Lethargy: Drowsy, may respond to verbal stimulation.
      • Stupor: May need painful stimulation to respond.
      • Coma: Unconsciousness, unresponsive to stimulation.
      • Decorticate rigidity.
      • Decerebrate rigidity.

Physical Appearance

  • Personal hygiene: Grooming, choice of clothes.
  • Behavior:
    • Mood: Emotion or feeling – how you feel.
    • Affect: Expression of emotion – how you act.

Cognitive and Intellectual Abilities

  • Level of orientation: Person, place, time, situation.
  • Memory:
    • Immediate.
    • Recent: Current admission/appointment, today’s events.
    • Remote: Recollection of past facts.
  • Ability to calculate.
  • Abstract thinking: Example needed.
  • Client’s judgment: Example: response to a fire?
  • Perception of illness: Etiology? Management?
  • Rate, volume, and speech coherence.

Standardized Assessment Tools

  • Mini-Mental State Examination (MMSE):
    • Orientation to time and place.
    • Attention span, ability to count backward.
    • Memory and recall.
    • Language: Obeying commands, ability to write.
  • Glasgow Coma Scale.
  • Pain scales.

Vulnerable Populations

  • Special considerations needed for:
    • Children, elderly, physically disabled, hearing-impaired, non-English speaking, cognitively/intellectually impaired, recent trauma, etc.
  • Customization of patient-centered care is essential.

Lifespan Considerations

  • Children and Adolescents:
    • Social and environmental factors.
    • Developmental stage.
    • History of trauma.
  • Attributes of the Mentally Healthy Child:
    • Trust, sense of security and safety.
    • Use of appropriate coping skills.

Mentally Ill Children: Points to Consider

  • Delayed or inadequate diagnosis and treatment due to:
    • Ability to express self/describe problem.
    • Variations about normal behavior/developmental task.
    • Parental fears/cultural biases and norms.
  • Assessment:
    • Mood/anxiety, developmental stage, behavioral, and eating disorders.
    • Use HEADSS (Home, Environment, Education/Employment, Activities, Drug and Substance Use, Sexuality, Suicide/Depression, Safety).

Older Adults

  • Assess for functional abilities (ADLs).
  • Economic and social status.
  • Environmental factors (residential structures).
  • Physical assessment.
  • Use standardized tools:
    • Geriatric Depression Scale (Short Form).
    • Michigan Alcoholism Screening Test for Geriatric Clients.
    • Caregiver Role Strain Assessment.
  • Safety at home (falls, ability to complete ADLs).

Conducting Client Interviews

  • Ensure quiet environment with adequate lighting.
  • Maintain your own safety.
  • Stand or sit at the same level with the client.
  • Introduce self, ask for the client’s preferred name.
  • Maintain appropriate eye contact and non-verbal communication.
  • Include family if the client wishes (must consider HIPAA).
  • Obtain detailed medication history.
  • Summarize the interview and ask for feedback.

Diagnosis of Mental Illness and the DSM-5

  • Published by the American Psychiatric Association.
  • Uses: Identification of mental health diagnoses.
  • Fluid document, changes over time.
  • Standardized assessment findings.

The Nursing Process

  • Examples of common diagnoses for plan of care.
  • Rule of physical before psychosocial and actual before at-risk.

Serious Mental Illness

  • Chronic (persistent or recurrent) mental disorder.
  • Remissions and exacerbations.
  • Ability to perform ADLs affected.
  • Often their own lives and/or the lives of others are at risk.

Role Changes and Mental Health

  • Losses: Employment, divorce, retirement, death.
  • Predictable and unpredictable role changes.
  • Change can be stressful and can lead to mental health strains.
  • Assessment following role changes:
    • Health status, ability to function.
    • Living conditions, level of information.
    • Coping and self-management.
    • Previous mental health history.
    • Support network.

Life Events and Mental Health

  • Even happy events can cause stress and anxiety; coping mechanisms can fail.
  • Especially cumulative events.

Legal and Ethical Issues in Mental Health

What is Ethics?

  • A set of moral principles about right and wrong.
  • Fundamental principles of moral conduct.
  • Why mental health nursing ethics:
    • Protection of patient rights.
    • Promotion of professional practice.
    • For patient safety.

Rights of the Mental Health Patient

  • Fundamental human rights:
    • Humane treatment (without prejudice, discrimination, or bias).
    • Right to medical/dental care.
    • Right to vote, obtain a driver’s license.
    • Right to legal services.
  • Specific mental health rights:
    • Right to have consent for treatment and refusal of treatment.
    • Interpreter services.
    • Confidentiality (Protected by HIPAA).
    • Plan of care, follow-up, and review of care.
    • Right to legal counsel, communication with family, and health professionals.
    • Freedom from physical or chemical harm including abuse and neglect.
    • Psychiatric advanced directive.
    • Provision of least restrictive care possible without being a threat to themselves or to others.

Ethical Principles

  • Autonomy: Respect a person's freedom to choose what's right for them.
  • Beneficence: All choices for a patient are made with the intent to do good.
  • Non-maleficence: Do no harm.
  • Justice: Treat and provide care fairly to all patients.
  • Fidelity: Keeping a commitment (promise) based on the virtue of caring.
  • Veracity: The principle of telling the truth.

Confidentiality

  • The right to privacy (HIPAA).
  • Client information cannot be shared with a third party without their written consent.
  • Client information can only be shared with health personnel directly caring for them.
  • Legal duties that seem to go against HIPAA:
    • Disclosing HIV status, warning and protecting others.
    • Reporting child and vulnerable adult abuse.

Sources of Information About Nursing Ethics

  • ANA Code of Ethics for Nurses (new version 2025!).
  • Patient Care Partnership.
  • The Nurse Practice Act (state-specific).
  • Legal advice.
  • Interprofessional health team.
  • Religious and spiritual counselors.

Types of Admissions: Informal and Voluntary

  • Informal Admission: Least restrictive, client not a threat to self/others.
    • Can leave the health facility anytime, even against the advice of the health team.
  • Voluntary Admission: Can be initiated by the client/guardian.
    • Client is competent, may discontinue admission or refuse treatment anytime.
    • The psychiatrist/health team may evaluate the client before release.

Types of Admissions: Temporary Emergency Admission

  • Medical health provider may initiate admission of a client for emergent care. In the case that it is against the client’s will, law enforcement is sometimes involved.
  • Client is unable to make their own care decisions but still may refuse medications.
  • Evaluation by a psychiatrist is required for this admission.
  • Client may be admitted for a maximum of 15 days.
  • Duration of admission may vary according to local laws and patient care needs.
  • Texas: Emergency Detention Order (EDO) 48 hours weekdays/72 hours weekends.
  • Very common for a client to be evaluated medically first.

Types of Admissions: Involuntary Admission

  • If the client is considered harmful to self/others, involuntary admission can be initiated.
  • The client is admitted to a mental health facility for a relatively long period of time.
  • Client is a threat to themselves/others and unable to maintain self-care.
  • The client is evaluated and found to require mental health care based on the following criteria:
    • Client is mentally ill, likely to harm self/others.
    • Client is severely disabled or cannot meet basic self-care needs.
    • Client is not able to seek voluntary treatment when they need it. (Determined by a judge)

Involuntary Admission, Continued

  • May be initiated by a family member, psychiatrist, legal guardian, or primary care provider.
  • Two physician evaluations are required.
  • Client may seek legal review anytime, legal advocate.
  • Duration: Up to 60 days, then legal/psychiatric review is required.
  • Client is considered competent with rights unless otherwise determined by the courts.
  • Long term admission: Imposed by a court for 60-180 days or longer.

Client Rights Regarding Seclusions and Restraints

  • Seclusion (Discussion):
    • What is seclusion?
    • Who can order seclusion?
    • How long does a seclusion/restraint last?
    • What are the indications?
    • When is seclusion wrong?
    • What are some less restrictive measures?
    • What is a temporary timeout?

Limits for Seclusion

  • 18 years and older = 4 hours
  • 9-17 years = 2 hours
  • 8 and younger = 1 hour
  • Duties of the nurse during patient seclusion.
  • Can the nurse initiate seclusion?
  • During seclusion:
    • Complete assessment and documentation every 15 minutes (or follow protocol).
    • Renewable every 24 hours following face-to-face evaluation by the physician.
    • High risk for injury during seclusion.
    • High risk for emotional damage.

Legal Issues: Laws of Tort

  • Intentional and unintentional torts.
  • The law is supreme, always.
  • Nurses need to know federal, state, and local laws related to mental health care.
  • Tort: A civil wrong committed against another, may include damage to people or property.
  • Tort is a willful action and is likely to be more common in mental health settings.

Intentional Torts

  • False imprisonment.
  • Assault.
  • Battery.

Unintentional Torts

  • Negligence: Failure to provide appropriate/adequate care to clients in violation of one’s professional obligation (code of ethics, facility policy).
  • Negligence must be proven.
  • A professional is liable when the following are met:
    • The nurse had the professional obligation to protect, the duty was breached, and their neglect directly caused an injury.
    • It must be proven further that if the act of protecting was done, the injury would not have occurred.

Malpractice

  • Malpractice is a form of professional negligence.
  • In malpractice, professional standards are compromised.
  • The health professional fails to provide standard care and causes harm to the client.
  • Clients who suffer negligence or malpractice may seek redress in a civil court.
  • Nurses are held to Nurse Practice Act - each state has their own - in place to protect the public, not to protect nurses.