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Health Assessment > Ch 9: Mental health, violence, drug abuse > Flashcards

Ch 9: Mental health, violence, drug abuse Flashcards

1
Q

What is not uncommon for people with mental health and how do they cope

A

It’s not uncommon for a person with mental health to not realize that they’ve had a problem for such a long time

The people tend to self medicate with alcohol and substances to cope

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2
Q

What is the world health organizations definition of mental health

A

Mental health is a state of wellness, realization of own abilities to go with stressors of life and how they contribute to the community

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3
Q

What is the relationship between Culture and health/ mental wellness (determines what)

What keeps many people from being treated for mental health

A

Culture determines the acceptable behaviors to mental health issues

Many people because of the negative stigma in terms associate with mental health do not seek treatment

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4
Q

What are common mental health disorders

4

A
  1. Depression
  2. schizophrenia
  3. PTSD
  4. substance abuse
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5
Q

When do you notice mental health issues when speaking to patients and what is vital to do after you notice the health issues

A

When doing the general survey (Hx) this is where you notice mental health issues

Once you determine a mental health issue you now need to guide your assessment and screen for the mental health

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6
Q

Give two mental health screening considerations
(especially for women) 

 why are these two considerations so important

A
  1. Culture/country
  2. Violence screening

-these two considerations determine for the patient what is acceptable cultural behavior



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7
Q

What is a Vital teaching two women about acceptable cultural behavior and how it relates to the United States

A

We must teach female patients that it is not acceptable in the US to have violence against women and the men can go to jail

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8
Q

When asking the patient questions what is a big red flag Upon their answers

A

After asking questions if patients are leaving information out or giving you different stories it’s a big red flag

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9
Q

What are vital components to the mental health assessment

(Bare components)

What do you want to do in response to patient behavior and answers

A 
Mental health assessment components:
-all questions
-all responses and behaviors by patient

 read patient behaviors and look into answers
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10
Q

What are signs when assessing for violence from a patient or family member that indicate anger
(give mnemonic)

What is your job when a patient or family member begins to become angry And what do you do if you cannot control the patient

A

Violence in patient/family members,
Assess with:

S-taring
Tone: loud
Anxious
Mumbling (due to anger)
P-acing
\+ pounding
  • When patient Or family becomes angry try to de-escalate the situation
  • If you cannot de-escalate the situation get out and get help
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11
Q

What are dos and don’ts with an angry patient

A

Do: State the patient’s name

Don’t: raise voice or become defensive

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12
Q

 when are you most likely to notice types of violence or abuse as a nurse in a hospital setting

What is the issue with human violence in women


A

During labor and delivery it’s most common to see violence or abuse

Human violence and women often goes unreported due to fear

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13
Q

What are signs of an abusive husband or partner in labor and delivery

What is vital for you to do in efforts to ask the patient if they are being abused

What do you do if your highly suspicious of abuse

A
  • The husband tries to control the entire conversation with the wife and nurse
  • does not let the wife answer
  • does not leave the wife’s side
  • often the abusee Will not look up and make Eyecontact

It’s vital to get the husband out of the room to ask the patient if they are being abused

-if highly suspicious of abuse you MUST Report


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14
Q

What are three ways to get an abusive husband out of the room to ask the patient if they are in danger or being abused

A

Ways to get a piece of has been out of room:

• tell husband to get wife some thing
• say you’ll be performing an assessment
• “take a break”


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15
Q

Why does child maltreatment occur

Why does sibling violence occur

  • what is the effect on the abusee
  • what must parents do

Give an example of intimate partner violence (IVP)
-what is the type of abuse in IVP

A

Child maltreatment :occurs because of
Low parent impulse control
-parents first reaction is to hit don’t even think about it

Sibling violence: occurs because abuse is often not taken seriously by parent

  • effects of abuse will be traumatic on abusee
  • parents need to pay attention especially to rivalry, roughhousing, competition
Intimate partner violence (IVP):
L & D couple with husband being abuser
-other than physical, threats or coercion Are taken on by abuser


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16
Q

What is the percentage of women who report rape, assault or stalking to be from who

A

2/3 A woman who report rape, salt, stocking or victimized by current or former partner’s

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17
Q

Give an example of Intimate partner violence (IVP) Within immigrants/refugees.

What are tactics used by abuser with immigrant and what does it result in for the immigrant

A

 IVP among immigrants/refugees:
-wife may be illegal and husband has total control

Abusive Husband may:
• threatened deportation
• threaten to leave patient with nothing (food, money, shelter ) 

-The abuse results in immigrant feeling trapped

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18
Q

Give types of elder abuse

Give elder abuse patterns
(presentations on older person) 

What type of older presentation do you specially look for abuse in

A

Elder abuse types:
-physical, neglect, financial exploitation, abandonment

Elder abuse patterns

  • Kicking
  • punching
  • slapping
  • burning
  • locking in room

Especially if an elder looks cachexic evaluate for abuse

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19
Q

What is the most common elder abuse

How does This abuse occur

A

Malnutrition is the most common elder abuse

Malnutrition occurs by:

  • taking money
  • not Bryan groceries
  • no one to care or cook for patient
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20
Q

What gender is at a greater risk of abuse in the collect

A

Older women or a greater risk for abuse and collect V older men

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21
Q

 what are the two types of violence against adults with disabilities
(cognitive issues)

Give an example of #2

A
  1. Intentional
    - means to harm and hurt the patient
  2. Unintentional
    -caregiver burnout
    : caregiver becomes burned out of having to do total care and takes it out on the patient

I.e: daughter burn out on mom

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22
Q

What is your action if you notice unintentional abuse of elder and describe it

A

If you notice an intentional abusive elder give caregiver:

RESPITE CARE:
-placing love one in a long-term care facility for about a week until the caregiver gets rest and recovers

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23
Q

What do you do if the patient needs exceeds the caregivers ability

A

If patient needs exceed caregiver ability:

  • give caregiver help
  • help put patient in long-term care facility
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24
Q

Why is sexual assault exceptionally high in women with developmental disabilities

A

Women with developmental disabilities are easy perpetrator victims and end up pregnant but don’t remember how

Must report!!!

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25
Q

What are common youth in school violence Actions among children

What is vital to teach kids about youth in school violence

A

Hitting
humiliating
bullying/cyber

If children witness bullying/school violence teach to report

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26
Q

When doing a cultural assessment on a patient what is vital to remember regarding sexual violence (marital rape) especially if they are not of your culture

What do you want to teach patient who suffer from marital rape when coming to the US

A

When doing cultural assessment on others who are not of the same culture:
Remember marital rape is not a crime in all countries

It’s vital to teach patients that it is not acceptable in the US and is a crime

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27
Q

 How do abusers get children to commit sexual acts

A

Abusers likely course children by threatening child into completing sexual act

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28
Q

What is the most common emotional response in sexual assault victims

A

The most common emotional response in victims of sexual assault is guilt

-victim will blame themselves

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29
Q

If no treatment what will the victims of sexual abuse become

A

If not treatment children who have been sexually abused will often become sex offenders

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30
Q

What are the domains of hate crimes and why are they done

A

Domains of hate crimes include:

  • race
  • ethnicity
  • gender
  • sexuality
  • religion

Hate crimes are done out of hate towards domains


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31
Q

 when should human trafficking be assessed

What are ways of human trafficking

A

Human trafficking should be assessed if family dynamic does not appear normal

Human trafficking businesses:

  • recruitment
  • Sex trade/ sexual exploitation
  • forced marriage
  • cheap labor
32
Q

Give the definition of human trafficking

A

Human trafficking: recruitment, transportation, transfer, harboring or recipient of people through threats, force, coercion

33
Q

What is another common name for war related violence

Why does war related violence occur

What is vital to do when assessing someone with war related violence

A 
War related violence equals PTSD

PTSD occurs because:
-witnessing/intentionally killing
- injuring others being injured 
-potentially killed

What assessing someone with PTSD it is vital to find triggers

34
Q

What are signs and symptoms of PTSD

A 
S&S of PTSD:
-nightmares
-feeling of guilt
-Poor concentration
-reliving event
    • especially with war movies! 
35
Q

What Is the highest concern/aspect(Paramount) to assess in human violence victims

What does Trust and rapport allow within patients and nurses

A

In human violence victims physical and emotional safety is key to assess

Trust and rapport allows:
Talking, trust, sharing

36
Q

 what must a nurse establish within patients to get them to communicate 

A

Patients must established trust and rapport with nurse to communicate effectively

37
Q

When conducting patient interviews/mental health assessments

-how must they be completed

-what is the talk to listen ratio
what do you use this time for?

-how do you prepare a patient for questions

A

When doing interviews/mental health assessments:

-interview must be done private and patient data must be confidential

-you should listen more than talking
80% pt/20% nurse
Used time to gather information and reppatient

-prepare patient by prefacing sense of questions saying
“ i’m going to be asking some very close and personal questions”

38
Q

During urgent assessments for mental health, violence, drug abuse what are the most important questions to ask

If a patient is suicidal what should be your next follow-up question

When hearing suicide plan what do you want to assess for

A

If patient is suicidal next follow up question is
“ do you have a suicide plan”

After hearing plan assess for means to do it

39
Q

Urgent assessment:

What are signs of depression in the patient

What will a patient in a psychotic state Believe and do

A

Signs of depression:

  • Poor eye contacts
  • poor grooming
  • slumped

Patients in psychotic states will believe they are being threatened and will attack

40
Q

Give characteristics of dementia with in patients

A

Dementia

  • gradual mental status change
  • disoriented X2
  • Irreversible
  • Common confabulation
  • patient cannot remember so they will make things up

Eventually leads to Alzheimer’s

41
Q

What is common among your Alzheimer’s and dementia patients at the end of the day

Define sundowner syndrome

How will patient present With sundowners syndrome

A

At the end of the day sundowners syndrome occurs between your Alzheimer’s and dementia patients

Sundowner syndrome is a natural late day confusion and fatigue due to low light causing an imbalance

Patient will be:
Confused/agitated late in day

42
Q

Give characteristics of delirium

What can Delirium be caused by + What does it lead to(how does a Present)

A

Delirium:
-sudden in onset
-disoriented X3
-reversible

Delirium causes include:
-alcohol withdrawal

Leads to disorganized thoughts and increased risk of injury

43
Q

What statements do you subjective data include

3 things

A

 subjective data include

  1. statements to the nurse
  2. overheard patient reporting(to someone else)
  3.  family and friends reporting
44
Q

What kind of questions do you wanna ask A patient during the mental health and violence assessment

How is the mental health and violence assessment in art and a science

A

 you want to ask patient open ended questions during mental health assessment

Mental health assessment is an art: -
-communicating and assessing patient accurately
Science:
-Accurate knowledge base of patient to screen in mental health

45
Q

What must you have in relation to the questions being asked

A

You must have the ability to listen and be comfortable with questions being asked related to psychosis, suicide, plan any form of abuse

46
Q

What are non-verbal actions you want to do when obtaining objective data for the mental Health assessment/violence

A

When obtaining objective data, follow
SOLER

S-it at eye level
O-pen inviting demeanor
L-ean forward to show interest
E: ye contact the patients level
R: relaxed position (do not cross arms)
47
Q

In patients with mental health issues what do you want to be aware of In regards to getting subjective data  and what are strategies used

A

patients with mental health may use diversion strategies such as
• asking personal questions
• insulting nurse to stop questioning
-Do not take personal but address the issue
• drift off

48
Q

What behavior will patients with psychotic disorders display

In a patient with a psychotic disorder what do you never want to do and why

A

Patients With psychotic disorders me laugh in appropriately or answer unlogically

Never laugh around a patient with a psychotic disorder as they may think you were laughing at them

49
Q

What age population is most likely to be depressed

What do support systems in patients with mental health resultant

A

Your older population is most likely to have depression

In those with mental health who have support systems, they have better outcomes and decrease cases of depression

50
Q

In assessment of risk factors what are

unchangeable factors

Environmental (changeable factors)

Metabolic issues/associated
physiological processes

A

Unchangeable: mental health family history, age, gender

Environmental (changeable factors)

  • any changes in support system
  • coping skills
  • does patient have family involvement?
Metabolic issues (May cause mental H issues) 
-Parkinson’s 
cancer
 HIV/AIDS

51
Q

If a woman presents with postpartum depression what do you want to ask her

A

In a woman with postpartum depression ask if she wants to harm self for a child

52
Q

When assessing violence, alcohol, drug use:

How do you assess alcohol use

What can a patient say that raises a red flag for suicide

With drug use what do you want to assess for

A

Asses alcoholic use with CAGE

C-ut down drinking
A-nnoyance With drinking criticism
G-Guilty
E-Eye-opener 
      •1st drink is alcoholic drink

If a patient says they have no sense of hope it is a red flag for suicide

For drug use assessed for mixing of trucks causing interactions

53
Q

Spiritually what do you want to assess for that will benefit the patient

A

Spiritually, assess for rituals that will help patient cope

54
Q

When educating on violence what do you want to give the patient information on

A

When educating on violence once separating from abuser give information on shelters

55
Q

Give the most common symptoms for altered mental status

A

Auditory, visual, olfactory, tactile hallucinations

Suicide ideation
-assess plan

homicide ideation/aggressive behavior
-Self mutilation what is causing this pain

Alter mood and affect

56
Q

If a patient is experiencing auditory hallucinations what do you want to ask the patient

What is pertinent to AVOID for patients undergoing auditory hallucinations

A

If Patient experiencing auditory hallucinations ask
“ what are the voices telling”

NEVER!!! Say the name of the voice because it makes it real for the patient

57
Q

Describe olfactory hallucinations

describe tactile hallucinations

A

Olfactory hallucinations: patient can smell fire even if it’s not there

Tactile hallucinations: unusual sensations

58
Q

What is the lifespan consideration when you’re pregnant women in relation to psychiatric disorders

A

Pregnant women me relapse in psychiatric disorders because of hormones

59
Q

How is being African-American/Hispanic a risk factor
-What are signs and symptoms

How does being of a lower socioeconomic status develop into a risk factor

A

African-Americans/Hispanics because of stigma with culture risk of not recognizing depression
S&S:
-Poor cognition
-decrease sleep/initiative

Lower socioeconomic status is do not have the money to seek help

60
Q

When do you use the geriatric Depression scale and what is the points game

A

Geriatric depression scale use in your geriatric if suspected depression.

Score breakdown:

5: suggestive of depression
- needs further evaluation
10: indicative of depression

61
Q

What is a suicide risk assessment commonly used

What is the point system

A

SAD PERSONAS Is a commonly used suicide risk assessment

Scoring: One point per category the higher the score the higher the risk of suicide

62
Q

what kind of care is cultural care

When using an interpreter for patient Mental health assessment what do you want to ask

what can the interpreter not do

A

Cultural care equals holistic care

When using an interpreter ask them:

  • did the patient make sense
  • did they voice any practices or beliefs
  • was the conversation flowing

Patient cannot give any information on the interview to family members or friends bound by confidentiality and patient knows

63
Q

How do you document an interview using interpreter

A

When using an interpreter document intro his name plus what interpreter has said

64
Q

Within different cultures and religions what are some acceptable practices

what is the percentage of the population that does not seek traditional care and why

A

Acceptable practices:

  • Witchcraft
  • voodoo
  • homeopathic
  • Christian science

About 1/3 of the population does not situational care because of its access, cost, poverty, language, no insurance

65
Q

When doing comprehensive assessment what is objective data you want to obtain

A

Objective data do you want to team includes:

- observing the patient and the patient’s behavior

66
Q

What may physical presentation be useful for

How is physical assessment assessed

A

Physical presentation may be the first indication of a mental health/violence issue

Physical assessment used based on ABCT

67
Q

Describe your ABCT for physical assessment

A

A-ppearance
-Overall appearance, posture, hygiene, dress

B-ehavior
-LOC, eye Contact, speech

C-ognative function
-assess orientation, attention, memory
• ask patients to add or subtract
• ask patient do you have somewhere to stay
• ask patients if they can solve problems


T- hought process and Perceptions 
-A&O x 3
-paying attention?
-Following conversation
68
Q

Give another name for MMSE.

Describe the mini mental state examination (MMSE)

Describe the MMSE scoring system

A

MMSE =Mini cog

Techniche:

  • List 3 unrelated words
  • Have patient draw a clock face and the time on the clock
  • Repeat the beginning three words

Scores:
• no words: demented
• recall all: not demented

69
Q

What are violence victims symptoms noticed during assessment

A

Easily triggered
isolation/ social withdrawal
shutting down feelings (numbing) spacing out

70
Q

 what are major signs of abuse in children elders and women you want to note

A
  1. injury not consistent with story
  2. Sexual activity younger than 14
  3. Failure to seek timely medical care
  4. Multiple hospital visits and fractures + bruises in different healing stages
  5. Burn configurations (cigarettes)
    
71
Q

in an abusee What nonverbal cues will alert you to abuse

If the patient opens up about being abused how must you document

A

Eye scanning
being very jumpy/clingy
guilt

If the patient tells you they are being abused document verbatim and a detailed and descriptive manner

72
Q

Who are mandated reporters and what is the report made in

What are the two people you report to

A

Nurses/healthcare workers are mandated reporters
-Reports are made in good faith without malice

Report to:
-charge nurse
-CPS

73
Q

When you call to report abuse to CPS what are the four things you must document about the call

A
  1. Reason for call
  2. Time of call
  3. Full name of who took the call
  4. Response of call taker (timeframe) 
74
Q

For people with dementia who do you have to defer personal questions

How well does someone with dementia follow instructions

what does a conversation of someone with dementia look like



A

In a patient with dementia refer personal questions to family members as patient is poor historian

Those with dementia unintentionally fail to follow directions

Those are dementia have difficulty following conversations

75
Q

Give nursing diagnosis related to mental health, violence, drug abuse

A

Risk for suicide

Altered mental status

76
Q

Give nursing outcomes related to mental health, violence, drug abuse

A

Patient does not harm self

Demonstrate social interaction

Identifies personal strengths

77
Q

Give nursing interventions related to the mental health, violence, drug abuse assessment

A

Assess for risk of harm to self, others

Provide safe environment by removing items that may cause harm

Identify support systems, involve them in care

Health Assessment (20 decks)

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