Chapter 10 Flashcards
The Psychiatric - Mental Health Nursing Process
what is the nursing process?
think of the anagram
ADIPE
assessment
diagnosis
planning
implementation
evaluation
what is the assessment in psychiatric mental health ?
deliberate and systematic collection of information or data to determine current and past health, mental health, wellness, strengths, functional status, and present and past coping patterns
the assessment always begins with obtaining a what?
chief complaint
during your assessment of a patient, you may ask what?
direct or indirect questions
what does the assessment of the physical domain include ?
dont over think it
current and past health status
physical examination of body systems
review of physical functions
pharmacologic
strength
wellness assessment
what are the 4 psychological assessments we are going to do for our patient ?
mental health problems
mental status examination
behavior responses
risk factor assessment
how are mental health problems assessed in a patient ?
identifiy any mental health disorders and their current strategies or behaviors in dealing with that disorder
how are behavior responses assessed in a patient ?
current and past patterns
and
how the patient views self
how do we assess risk factors in patients ?
ascertaining weather the patient has any suicidal, assaultive or homicidal ideation
when doing a mental status examination on a patient, how does it help us as nurses? (2)
establish a baseline of where the patient is currently at
creates a written record/ documentation
the mental status examination includes? (11)
general observations of apperance
psychomotor activity & attitude
orientation
mood and affect
emotions
speech
thought process
attention and concentration
abstract reasoning and comprehension
memory
insight and judgment
how are we assessing their general observations?
physical - underweight, overweight
dressing
behavior - guarded, irritable
what is the difference between mood and affect?
mood - the person feels
affect - how you think the person feels
how do we assess patients for speech ?
fruit salad, slowness, talking nonstop, skipping words, slurred
how do we assess a patient thought process?
delusional, hallucinations, illusion, psychotic
how do we assess a patients attention and concentration ?
are they focused, distracted
how do we assess abstract and comprehension ?
they can’t think outside of a metaphor, like giving them a metaphor and they can’t describe it
how do we assess memory?
ask a random question at the start of the assessment then re ask at the end
how do we assess insight and judgment?
their ability to recognize their own mental illness and their part in it
making good choices for themselves
what are some social assessments we are going to need to ask or find out ?
dont over think it
functional status
social systems
spirtuality
occupational, economic, legal status
the nursing assessment should provide data for nursing diagnoses and planning with the patient for mutually agreeable outcomes
- anticipated patient outcomes provide direction for psychiatric - mental health nursing interventions
what are some examples of biologic nursing interventions ?
self care
sleep
nutrition
what are some examples psychological nursing interventions ?
behavior therapy
counseling
health teaching
what are some examples of social nursing interventions ?
community and home interventions
milieu therapy
evaluation of patient outcomes involves what 3 things?
cost-effectiveness
benefit to the patient
patients level of satisfaction
how should outcomes be measured after an interventions is performed?
immediately
or after some Time passes
chapter 10 : the psychiatric- mental health nursing process part 2
risk assessment
when it comes to risk assessment we usually like to give two main categories, suicide and homicide. however the questions are going to be the same
the following are the 5 main questions we are going to ask patients and document when assessing their risk of suicide or homicide
what is ideation mean ?
what is plan mean?
what is means mean?
what is intent/prepartion mean?
what is history mean ?
do you have these thoughts ?
do you have a plan to do this?
can you get the materials do to this?
do you want to carry this out, do you have this prepared ?
have you done this before, how lethal was the attempt before ?
in suicide, you have an active and passive, can you describe each ?
active suicide
- you are actively thinking about suicide
passive suicide
- “just like to die”
- “family better off without me”
when a patient has homicidal thoughts you as a nurse have the responsibility to what?
duty to warn!
inform the people around and the person who is going to die
for suicide risk factors, you have two forms, which are ?
acute ( modifiable )
chronic ( static )
what is acute modifiable suicide risk factors?
anxiety, impulsivity, substance use, self-injurious behaviors, stress
what is chronic (static) suicide risk factors?
previous suicide attempt
age, gender
chronic medical problems
family history of suicide attempt
psych illness
its also very important to try to help mitigate risk factors, how can we do this or assess for this ?
no previous history
denies si
no alcohol
no weapon in the home
absence of mental health illness
develop crisis response plan
questions 1
A 36-year-old patient with a diagnosis of depression who has attempted suicide says to the nurse, “I should have died. I’ve always been a failure. Nothing ever goes right for me.” Which response by the nurse demonstrates therapeutic communication?
A. “You have everything to live for.”
B. “Why do you see yourself as a failure?”
C. “Feeling like this is all part of being depressed.”
D. “So have you been feeling like a failure for a while?”
D. “So have you been feeling like a failure for a while?”
question 2
The nurse visits a patient at home. The patient states, “I haven’t slept at all the last couple of nights.” Which response by the nurse demonstrates therapeutic communication?
A. “I see.”
B. “Really?”
C. “You’re having difficulty sleeping?”
D. “Sometimes I have trouble sleeping too.”
C. “You’re having difficulty sleeping?”
Question 3
A 19-year-old patient experiencing disturbed thought processes
believes that his food is being poisoned. Which communication technique should the nurse use to encourage the patient to eat?
A. Using open-ended questions and silence
B. Sharing personal preference regarding food choices
C. Documenting reasons why the client does not want to eat
D. Offering opinions about the necessity of adequate nutrition
A. Using open-ended questions and silence
question 4
A 57-year-old high school teacher diagnosed with terminal cancer says to the nurse, “I’m going to die, and I wish my family would stop hoping for a cure! I get so angry when they carry on like this. After all, I’m the one who’s dying.” Which response by the nurse is therapeutic?
A. “Have you shared your feelings with your family?”
B. “I think we should talk more about your anger with your family.”
C. “You’re feeling angry that your family continues to hope for you to be cured?”
D. “You are probably very depressed, which is understandable with such a diagnosis.”
C. “You’re feeling angry that your family continues to hope for you to be cured?”
