Chapter 1 - Basic Mental Health Nursing Concepts Flashcards
Mental Status Examination
Level of consciousness
alert
lethargy - drowsy
stupor - requires vigorous/painful stimuli for brief response
coma - no response
Decorticate rigidity
flexion and internal rotation of upper-extremity joints and legs
Decerebrate rigidity
neck and elbow extension, wrist and finger flexion
Mental Status Examination
Physical appearance
expected - hygiene, dressed appropriately
Mental Status Examination
Behavior
in/voluntary movements, eye contact
mood - emotion felt
affect - objective expression of a mood (flat affect or lack of facial expression)
Mental Status Examination
Cognitive and intellectual abilities
orientation to time/person/place
memory (immediate/recent/remote-verified data from past like DOB)
knowledge - understanding of current illness
calculate - math
abstract thinking
objective assessment of perception of illness
response to a hypothetical question
rate, volume, quality of speech
Mini-Mental State Examination
objectively assess cog status orientation time/place attention span, count backwards by 7 register/recall objects language, following commands, writing
Glasgow Coma Scale
evaluate eye, verbal, motor response
15 = awake and appropriate
7 or less = coma
Considerations
Children and Adolescents
mentally healthy = trust world/others
Standardized assessment tool = HEADSS (Home, Education/employment, peer group Activities, Drugs, Sexuality, Suicide/depression
Considerations
Older Adult
comp assessment of: functional ability, economic/social status, environment, physical Geriatric Depression Scale Michigan Alcoholism Screening Test Mini-Mental Status Exam Pain assessments
Mental Health Nursing Interventions
Counseling Milieu therapy Promotion of self-care activities Psychobiological interventions Cognitive/Behavioral therapies Health teaching Health promotion/Health maintenance Case management
Mental Health Nursing Interventions
Counseling
Ther. communication skills
assisting with problem solving
crisis intervention
stress management
Mental Health Nursing Interventions
Milieu therapy
orienting client to physical setting
identifying rules and boundaries of setting
ensuring safe environment
assisting client to participate in appropriate activities
Mental Health Nursing Interventions
Promotion of self-care activities
offering assistance with self-care tasks
allowing time for client to complete self-care tasks
setting incentives to promote self-care
Mental Health Nursing Interventions
Psychobiological interventions
admin meds
provide teaching about meds
monitor for adverse effects and effectiveness
