final Flashcards
nurses have a key role to play in examining….
global health issues, developing solutions, and implementing change at both local and global levels, important activities are informed by an understanding of health equity & social justice concepts in order to respond to pressing health & social challenges
what is culture
- shared patterns of learned values & behaviours that are transmitted over time & distinguish the members of one group to another
- can include language, spiritual, and religious beliefs, socioeconomic class, gender, sexual orientation, age, group history, geographic origin, and education, childhood & life experiences
what are the 4 pillars
harm reduction, prevention, treatment, law enforcement
ethnicity
groups whose members share a social and cultural heritage, members feel sense of common identity
- may share common values, language, history, physical characteristics, and geographic space (Japanese, Irish)
race
common biological attributes shared by a group
ex: skin colour
cultural safety
considering the redistribution of power and resources in relationship. The notion “based on premise that culture used in broadest sense to apply to any person who differ from nurse bc of socioeconomic status, age, gender, sexual orientation, ethnic origin
purpose of indigenous cultural safety and anti-racism standard is to
set clear expectations for how BCCNM registrants are to provide culturally safe & anti-racist care for Indigenous clients. this standard is organized into 6 core concepts
6 core concepts & principles of cultural safety
- self-reflective practice (it starts with me)
- building knowledge through education
- anti-racist practice (taking action)
- creating safe health care experiences
- person-led care (relational care)
- strengths-based & trauma-informed practice (looking below the surface)
culturally sensitive care
- being culturally knowledgeable
- being client centered
- being self-reflective
- recognizing conflict of client/nurse values
- facilitating client choice
- incorporating client’s cultural preferences
- accommodating client’s beliefs & practices
conveying cultural sensitivity
- address by last name
- introduce yourself, explain your role
- use appropriate eye contact
- be genuine and honest (about lack of knowledge)
- respectful language (based on client’s preference and acceptable norms)
- do not make assumptions
- respect the client’s values, beliefs, and practices
- show respect for client’s supports/family
cultural awareness
beginning step to understanding there is difference
cultural sensitivity
(Being aware that cultural differences and similarities between people exist without assigning them a value – positive or negative, better or worse, right or wrong)
(ppt) = alerts nurses to the legitimacy of differences and begins a process of self-exploration as powerful bearers of their own realities which have impact on others
cultural safety
outcome of nursing education that enables safe service to be defined by those who receive the service
sociocultural theory
looks at interaction b/w people, social structure, relationships, and the “culture” which they live, work and play
- human learning is largely a social process
sociocultural assessment PNUR variable assessment guide
- language & communication patterns: verbal/nonverbal
- cultural roles & expectations
- social history: family, education, and work
- relationships/significant others
- health beliefs, habits, practices
- ethnicity and race
- avoid stigmatizing language
- loss in translation especially with someone who doesn’t have english as first language
- gender roles
- coping strategies
ecomap
visual assessment tool depicting the various systems in an individual’s life, including relationships, communities, work, education
symbols used to express energy that flows from person or family to other important people and elements of their environment
genogram
concise visual depiction of the family structure and relevant situational information used in nursing assessments
what is spirituality variable important for
coping
spirituality is
that which arises out each person’s unique life experiences and their effort to find meaning & purpose
religion is
a particular system of worship & faith; an organized system of beliefs and practices
faith is
belief in something, even when there is no evidence or proof; can involve the belief in a God or doctrines of a religion
spiritual health
feeling of being generally alive, purposeful, and fulfiled
what behaviours indicate spiritual health or spiritual well-being
peace, unconditional love, happiness, compassion
meaning/purpose means
derived form client when search for insight & expression of underlying feelings regarding philosophy of life, values, and beliefs about health & health challenges is explored. when individual experiences altered state of health, finding meaning within experience may be difficult
interconnectedness
individual’s sense of love, belonging and connection to self, others, a higher power, nature and cosmos
faith
belief in unseen or unknown, firm belief in ability to draw on spiritual resources with certainty despite any evidence or proof
religion
system of organized worship ascribing a set of doctrines with person practices. practice of religion is only one way an individual may express their spirituality
forgiveness
may not have meaning to all groups, clients will describe situations where either they cannot forgive themselves, others can’t forgive them, or they can’t forgive others. idea here is explore their ability to forgive others and their openness to accept forgiveness from others as a starting point of “letting go” of past feelings of hurt, anger, resentful, betrayed, & devastated
creativity
an activity producing a sense of peace, comfort, and soulfulness for individual
transcendence
process/experience beyond usual sensory phenomena. often associated with classic mystic experiences of God. not reserved for religious experience alone, may be related to aesthetic reactions to art and music or response to majesty of creation (regarding a feeling of wonder or awe)
spiritual distress
disturbance in person’s core value system, which provides strength, hope, and meaning to life
how can nurses support religious or spiritual practices
holy days, sacred writings, spiritual symbols, prayer/meditation, beliefs: diet/nutrition, dress, birth/death, medical procedures
4 basic elements of normal movement/mobility
- body alignment (posture)
- joint mobility (ROM)
- balance
- coordination
rom is
max movement possible for a joint
rom varies and determined by
age, health and overall activity level, genetics, general health status (baseline health)
rom can be
active or passive
active rom is
done first as its less intrusive
- uses patients own strength to create movements through the joints
- ask the patient to slowly move each joint through it’s full ROM (flexion, extension)
- tell patient to stop the movement and tell you if they experience any pain
passive rom is
more intrusive as you manipulate the person’s joints for them
- tell patient to relax and then support the joint and move it through its range of motion
- observe and compare each side of body for symmetry, pain, inflammation or stiffness
factors that impair mobility
- congenital or acquired postural abnormalities (scoliosis)
- damage to CNS as it regulates voluntary movement
- impaired muscle development (MS)
- direct trauma to the musculoskeletal system (fracture)
- inflammatory diseases (rheumatoid arthritis)
- bed rest or reduced activity tolerance
- pain
- medications
what is rheumatoid arthritis
chronic inflammatory disease primarily impacts synovial membrane but may impact other systems/organs (lungs, pericardium)
rheumatoid arthritis has what 2 effects
systemic & local (inflamed knee)
what is the cause of rheumatoid arthritis
unknown (autoimmune disease, genetic factors, infection), known to be exacerbated by stress
symptoms/assessment for rheumatoid arthritis (r/t inflammation)
objective: heat, redness, swelling over joint, tenderness
subjective: pain, fatigue, report flare ups, morning joint stiffness
rheumatoid vs osteoarthritis
- RA systemic autoimmune disease
- osteoarthritis is degeneration of joints that causes localized pain
etiology of osteoarthritis
most common chronic condition of the joints, involves a progressive localized deterioration of CARTILAGE in the joints leading to inflammation of the joints
risk factors osteoarthritis
- most common in ppl older than 65
- increasing age, obesity, previous joint injury, overuse of joint, weak thigh muscles, genes
signs/symptoms of osteoarthritis
symptoms: pain that worsens with activity, joint stiffness, and loss of function, decreased ROM
signs: limited joint motion, crepitation
health promotion for osteoarthritis
encourage weight bearing exercises, increase vit D & Ca intake; teach and encourage ROM exercises
what is osteoporosis
brittle bones
etiology of osteoporosis
decreased density of bones and deterioration of bone tissue, leading to bone fragility and increased risk for fractures
- bone mass is lost faster than can be absorbed
- commonly seen in hip, wrist, and spine
risk factors for osteoporosis
- gender: female
- age (65+)
- post-menopausal (early menopause)
- ethnicity: white, asian
- history of fractures (minor falls/imjuries)
- family history
- bone structure/body weight
- smoking
- alcohol abuse
health promotion/prevention of osteoporosis
- diet, exercise
- fall prevention
immobility can lead too
- disuse osteoporosis
- muscle atrophy & deconditioning
- contractures
- stiffness and pain in the joints
- cardiovascular changes (orthostatic hypotension)
- metabolic changes (loss of calcium)
- respiratory complications (atelectasis, pneumonia)
- urinary changes (increased risk for urinary stasis)
- poor hygiene r/t immobility can lead to skin breakdown, and sustained pressure on joints can lead to pressure ulcers
assessment of hair
- uniformity/thickness
- colour
- amount of hair (alopecia)
- body hair (lanugo)
- texture (oily/dry)
- scalp is free of lesions
- parasites (lice)
assessment of nails
- texture: smooth, thick/thin
- colour: cap refill, cyanosis
- cleanliness
- length (nail biting)
- shape & curvature
documenting and assessing a wound you want to describe:
- type (pressure ulcer)
- size, shape, and texture
- colour
- location/distribution
- surrounding skin
- elevation
- exudate/discharge
- odour
- measure height, width, and depth
pressure ulcer (decubitus ulcer) risk factors
immobility, age, obesity, incontinence, nutrition, braden scale for predicting risk
skin assessment: objective inspection
- colour: pallor (pale), erythema (red), cyanosis (blue), jaundice (yellow)
- redness, open wounds, lesions
- edema
- bruising, moles
- tattoos, marking
- rash, scratches/itchiness
- mucous membranes: pink, moist, intact
skin assessment: objective palpation
- temperature: use hand & feel the skin: indicates circulation/infection
- moisture: look for dryness, flaking: dehydration, eczema
- turgor: hydration status, age
- edema: swelling, fluid retention in tissues
- texture/thickness: smooth, rough, thin, uniform
goals must be
singular, observable, measurable, time-limited, mutual, and realistic
universal experiences in the PNUR conceptual framework
- crisis (stress, anxiety)
- comfort (pain)
- hope (hopelessness)
- loss (grief)
- power (powerlessness)
- resiliency (coping, strengths)
- integrity (death, dying, acceptance)
what is stress
- stimulus, a process, a response & a state
- highly subjective
- caused by internal or external factors
a stress response does what
demands that exceed one’s ability to cope & continuum with anxiety and crisis
3 components of stress response
- physiological component
- cognitive component
- emotional component
physiological response: general adaptation syndrome
stage 1: alarm reaction
stage 2: resistance stage (maintains high state of arousal)
stage 3: exhaustion stage (diverse health issues)
cognitive component
appraisal of stressors & how they influence stress response
lazarus & folkman cognitive appraisal theory
- person under stress only if they perceive themselves to be
- primary appraisal: what does situation mean to me?
- secondary appraisal: can i cope with it?
emotional component
thoughts –> emotions –> behaviour
anxiety is the
apprehension or dread in response to internal or external stimuli that can be experienced in physical, emotional, cognitive & behavioural ways
- ranges from mild to severe/panic level
- usually thoughts/feelings go negative
mild anxiety
slight arousal that enhances perception, learning and productivity
moderate anxiety
increased arousal with tension, nervousness and perception is narrowed
severe/panic anxiety
consuming, poor focus, very uncomfortable and requires intervention
- overpowering and frightening
adaptive coping
- strategies that minimize/reduce or eliminate the stress response
- strategies can be short-term/immediate, or longer term adaptations
ex: sleeping, meditation, exercise
maladaptive coping
- may temporarily be “effective”, but cause longer term negative consequences and results in worsening distress
- defense mechanisms - denial, projection, regression
comfort and the role of the RPN
- comfort is closely related to caring
- is an essential part of our role as RPN
- may involve consolation, support or assistance to promote well-being
hope is
anticipation of a continued good or of an improvement in, or lessening of something unpleasant
power is
perception & process of gaining or maintaining control or influence over aspects on one’s environment
as rpn we must (power)
recognize & minimize power differential inherent in our therapeutic relationships and practice
- goal is to empower clients by mobilizing their strengths
developmental crises
retirement, empty nest, puberty (short-lived)
situational crises
- illness
- death of a loved one
- separation or divorce
- loss of job
- moving
- traumatic experience
- unplanned prego
crisis intervention
- early intervention
- stabilization
- facilitate understanding
- problem solving
- encourage self reliance
role of the rpn
- establish a TR
- gather relevant data
- bear witness to their pain
- validate their feelings
- provide education
- teach new coping skills
- offer hope
grief
the emotional response (subjective) to the perception of loss
actual loss
a loss of a person or object that can no longer be felt, heard, known or experienced
perceived loss
a loss that can’t be seen by others (menopause, not getting a job you wanted)
bereavement
the response to the loss or death of a loved one
common symptoms of grief
- feel physically drained
- can’t sleep
- forgetful, can’t think clearly
- appetite changes
- physical symptoms: chest pains
- poor concentrations
- sense or dreams about deceased
- guilt
- tearfulness
- sadness that comes in waves
- numbness
factors that impact grieving
- personality and temperament before the loss (external vs internal locus of control)
- degree of attachment with the person who died
- culture & religious background
- nature of the loss (sudden or traumatic)
- presence of pre-existing mental illness & coping skills
- amount of support they have
- number or previous losses person as experienced (grief is cumulative)
- bereaved person feels responsible in some way for loss
normal grief
- self esteem intact
- good days/bad days
- maintains feelings of hope
- able to experience pleasure
- accepts comfort from others
- physical; symptoms are transient
clinical depression
- self esteem is disturbed
- feel persistent dysphoria
- feelings of hopelessness
- anhedonia is prevalent
- does not respond to support from others
- expresses chronic physical complaints
complicated grief
stuck in the grieving process, defined as unhealthy mourning following a death, lasts at least 6 mon
(pt doesn’t progress through the stages of grief, preoccuption with the deceased, recurrent intrusive images, avoidance of painful reminders of death, grief response continues to impact daily living, seek isolation, extreme feelings of guilt, meet criteria for major depression)
anticipatory grief
the emotional experience of the normal grief response before the loss actually occurs
role of the rpn related to grief
- assess stage of grief proccess
- develop trust, show empathy & unconditional positive regard
- provide ongoing support
- help client actualize the loss by talking about it
- help client identify and express feelings
- understand and explain the normal grief process
- be present and bear witness to their pain
- identify maladaptive coping strategies
concept of integrity
means “whole & complete”
- quality of having an inner sense of “wholeness” and consistency of character
- satisfaction of attaining own life goals
medication administration definition
preparing, giving, and evaluating the effectiveness of prescription and non-prescription drugs
role of psych nurse when administrating meds
- be knowledgeable about your practice standards
- educate yourself on the drug you are administering
- educate yourself on what could go wrong once you give it
- identify any barriers to medication compliance
- carry out nursing process
BCCNM medication administration
- responsible for administering meds within scope of practice
- knowledgeable about effects, side effects, and interactions of meds & take actions as necessary
- adhere to 7 rights of meds admin
- administer only meds they themselves or a pharmacist have prepared
- DO NOT pre-pour meds because it increases likelihood of errors
- take appropriate steps to resolve & report meds error or near miss
7 rights of medication administration
- right medication
- right client
- right dose
- right time/frequency
- right route
- right reason
- right documentation
pharmacology
study or science of drugs
- RPN needs to know pharmacological principles so they can understand how each drug given will affect the patient (both beneficial & adverse effects)
generic name
- the name given to the drug by the developer of the medication
- becomes the official name and us used in all formal publications
- acetaminophen, ibuprofen
trade name
- also known as brand name, this is commercial name given to a drug by the manufacturer, can vary in different countries
- tylenol, advil
chemical name
describes the medication’s molecular structure
- N-acetyl-para-aminophenol
drug classification
indicates the desired effect on the body system
- tells you what type of drug it is
- antipsychotic, antihypertensive
medication forms
form of the med indicates the route of administration
- nurses must ensure they use the correct form of medication as this affects absorption and metabolization
- tablet, ointment, suppository
pharmacodynamics
study of what the drug does to the body
therapeutic effect
intended or expected effect on the body
- tylenol will relieve headaches
side effect
unintended secondary effects
- morphine may cause rash
adverse effect
serious, negative effects
- gravol may cause hallucinations
toxic effect
a build-up or accumulation of medication in the body, to the point where it poisonous
contraindication
any characteristic of the patient (disease state, other medication, pregnancy) which makes the use of the medication dangerous for them
pharmaceutics
how various medication forms/routes influence the way in which the body metabolizes a drug and the way in which the drug effects the body
- oral, sublingual, subcutaneous, IM, IV, transdermal, inhalation, topical
pharmacokinetics
how the medication moves into, through and out of the body (absorption, distribution, metabolism and excretion) (pharmacokinetics)
absorption
movement of the drug from the site of administration to the bloodstream (pharmacokinetics)
distribution
transport of a drug in the body by the bloodstream to its site of action (pharmacokinetics)
metabolism
biological transformation or metabolic breakdown of a drug in the body (common in liver) (pharmacokinetics)
excretion
elimination of drugs from the body
- kidneys are primary way that drugs are eliminated from body (pharmacokinetics)
ways meds get into body: parenteral
IV IM subcutaneous (pharmacokinetics)
ways meds get into body: inhalation
nebulizers, nasal sprays(pharmacokinetics)
ways meds get into body: transmucosal
sublingual (pharmacokinetics)
ways meds get into body: gastroenteral
PO, suppositories (pharmacokinetics)
ways meds get into body: topical
patches, creams, ointments (pharmacokinetics)
onset of action
time it takes for the drug to elicit a therapeutic response
(pharmacokinetics)
peak effect
(pharmacokinetics)
- time needed for a drug to reach its max therapeutic response
duration of action
(pharmacokinetics)
- length of time that the concentration is sufficient to elicit a therapeutic response (time it lasts before it wears of)
half-life
(pharmacokinetics)
- time it takes for one half of the drug in the body in the body to be removed (eliminated from the body)
schedule I, IA, II, III, IV must be
sold from a licensed pharmacies
schedule I
need a prescription in order to self (amoxicillin)
schedule 1A
abuse potential drugs, require a triplicate/duplicate prescription in order to sell (MD keeps copy, pharmacist keeps a copy - to prevent forgeries and for prescription tracking purposes)
- T3’s, fentanyl
schedule II
no prescription required but pharmacist supervises the sale (medications are kept behind counter)
- T1’s, cough syrup
schedule III
drugs that can be sold without a prescription by a pharmacist (medications are locked in grocery stores after pharmacy closes)
- hydrocortisone topical cream
schedule IV
prescription by pharmacist
unscheduled
no restriction on sale of this drug
common OTC meds you should know
- NSAIDs (non-steroidal anti-inflammatory drugs, ASA & advil)
- non-opioid analgesics (acetaminophen)
- anti-emetics (dimenhydrinate = gravol)
- antihistamines (diphenhydramine = benadryl)
natural health products (NHPs)
complementary medicines or traditional remedies based on premise that plants contain natural substances that can promote and alleviate illness (weed, melatonin)
advantages of NHP
adjunct therapy to support conventional pharmaceutical therapies
disadvantages of NHP
- drug interactions
- allergic reactions
- adverse side effects
- people believe they are safe due to “natural” label
RPN role about OTC & natural products
- remain knowledgeable about OTC & natural health products
- know what’s out there on the market
- know drug-drug interactions
- ask for ALL medications that patient is on
- teach patient about side effects, risks
assessment for med admin
- gather comprehensive med profile:
1. all meds your pt takes on reg basis
2. history of allergies
3. use of OTC & natural products
4. intake of alcohol, tobacco, caffeine
5. illicit drug use
6. past/present health/med history
7. family history
8. client’s beliefs about their meds and their effectiveness
examples of diagosnis r/t med admin
- variance in knowledge base (knowledge deficit
- variance in protection (risk of injury from over-medicating)
- variance in health beliefs (non-adherence)
planning r/t med admin
- goals are patient focused
- include time frame
- ex: pt will take meds as prescribed on daily basis
interventions r/t med admin
- based on evidence based practice
- done as independent nursing functions or as collab
- ex: nurse discuss side effect profile w/ patient and how to manage each side effect
admin medications rules
- read dr. orders & check it against MAR to ensure they match
- dr orders transcribed onto the MAR by either the nurse or unit clerk
- contact dr/pharmacy to clarify any unclear or questionable orders prior to admin
- never leave poured meds unattended
- plan your time wisely so that the meds given within 30 min of ordered time
- don’t let yourself multi-task or be distracted while pouring or admin meds
steps to admin meds
- provide interventions as needed (BP pre/post)
- ensure 3 med checks
- identify client by name and check wrist band against MAR
- inform client about what med you are giving, listen to them if they express a concern
- don’t forget to ask about allergies prior to giving meds
- admin the drug
- record the drug admin on MAR & if prn then record in nurse notes NEVER sign off med prior to giving it
- evaluate & document the client’s response to drug in nurse notes
medication adherence
- watch terminology – “noncompliant” can be very judgmental
- when pt stops meds, we need to be curious & open to their reasons (normalization)
- pts beliefs about their meds will dictate their commitment to taking them as prescribed
- consider how these meds may be impacting their self concept
- remember TR skills
- using open-ended qts that access pts motivations, hopes and plans can help elicit
- clients are often misinformed about meds, providing accurate education to your clients about their meds is a large part of your role as psych nurses
- DO be collaborative and curious
lifespan assessmnet
- timetable of events, expected and unexpected, over the course of a person’s life
- looking at significant events holistically to better understand the person’s experiences over time and the journey to where the person is now and where the person may be headed
significance is
determined by the client’s perception and meaning of an event as well as developmental theory
expected life events
Refers to those occurrences that are common for the majority of people who share a similar sociocultural
context
unexpected life events
Refers to those occurrences that are not foreseen, unpredictable, and not a usual part of that stage of life. If a person does not experience an expected life event, this may result in an unexpected life event.
growth
Expected patterns of physiological growth and changes that occur throughout the lifespan.
development
Physiological, psychological, moral, social, and spiritual maturational patterns. It is valuable to know the
expected developmental milestones in order to assess for possible congenital/developmental delays or
deficits.
transition
Significant events when a person questions their life, considers new possibilities, and makes crucial new
choices.
adolescence, young adults, middle adults, older adults age
- 12-18
- 19-39
- 40-64
- 65+
normal development of adolescent
- physical changes: increase in bone & muscle growth, hormone fluctuations leading to development of sex characteristics, acne, hair growth, massive brain growth & pruning, poor impulse control
- self identity
- gender identity, peer relationships, sexuality, independence from family unit
- health risks
- MVA accidents, violence, suicide, substance abuse, eating disorders, STI’s, depression
normal development of young adults
careers, marriage, raising children
physical changes of young adults
physical growth is completed by 20 yrs
- active and at their peak physical health
- tend to avoid seeking help due to illness
psychosocial changes of young adults
- choosing an occupation, pursuing education
- developing intimate, more mature relationships
- achieving financial independence
- parenthood, body images issues
health risks of young adults
lifestyle habits, accidents, substance abuse, fertility issues, stress, pregnancy, mental illness
middle adulthood characteristics
- sandwich generation = taking care of children & their parents
- financial responsibilities
- balancing career & family
- adjusting to or fighting against the aging process
normal development (physical changes) middle adults
- major physical changes (grey hair, wrinkles, metabolic changes)
- decrease in hearing and vision
- hormone fluctuations for both men and women (menopause, testosterone decrease)
normal development (psychosocial changes) middle adults
- assisting children as they leave the nest
- dealing with separation/divorce or death of. aloved one
normal development (health risks) middle adults
- stress, anxiety, depression, obesity, long term effects of poor lifestyle choices
normal development (physical changes) older adults
- normal physiological changes in most body systems (decreased muscle mass, degenerative joint changes, lower cardiac output, decreased elasticity)
normal development (psychosocial changes) older adults
- retirement, transitions & role change, social isolation
- maintaining sexual identity
- spiritual variable should be assessed
normal development (health risks) older adults
cancer, heart disease, delirium, dementia, arthritis, falls
overview of erikson’s 8 stages of social and emotional development
- believed personality develops in a series of stages
- in each stage, each person needs to accomplish a particular task (challenge) in order to move onto the next stage
- each stage builds upon the successful resolution of the previous developmental challenge
- unsuccessful resolution of one stage will result in the chronic inability to master these tasks
what stage is teens into 20’s in
identity vs role confusion
description of tasks in identity vs role confusion
teens work at refining a sense of self by testing roles and then integrating them to form a single identity, or they become confused about who they are
approx age of 20’s to early 40’s, what stage
intimacy vs isolation
description of tasks in intimacy vs isolation
young adults struggle to form close relationships and to gain the capacity for intimate love, or they feel socially isolated
approx age of 40’s to 60’s, what stage
generativity vs stagnation
description of tasks in generativity vs stagnation
middle-aged discover a sense of contributing to the world, usually through family and work, or they may feel a lack of purpose
approx age of late 60’s and up, what stage
integrity vs despair
description of tasks in integrity vs despair
when reflecting on their life, the older adult may feel a sense of satisfaction or failure
what is MSE
- structured approach to assessing psychological, emotional, social and neurological functioning
- attempt to objectively describe the behaviours, thoughts, feelings, and perceptions of patient throughout course of interview
- provides overall picture of CURRENT mental health
- clinical knowledge, judgment, interpretation, & communication skills are required to do it well
- uses a combination of observation (objective) & questioning (subjective)
how is MSE done
- not conducted as separate, focused assessment, bur rather woven into interview
- some aspects more “formal” (assessing cognition)
- sensitive qts should be asked after more general, less sensitive topics addressed & rapport is established
when is MSE done
- during initial assessment (may assist in establishing a baseline)
- throughout the treatment process to establish changes in baseline response to treatment
- when behavioural changes are evident
- after a event or injury that may impact mental status
- ALL THE TIME
components of an MSE
- appearance & behaviour
- mood & affect
- speech
- thought form/process
- perception
- cognition
- insight & judgement
- risk assessment
appearance
(objective data)
- sex, age, height/weight, ethnicity/face, grooming/hygiene, distinguishing features, eye colour, hair colour, length
behaviour
(objective data - behavioural snapshot)
- psychomotor retardation or agitation
- hyperactivity, restlessness, repetitive movements
- eye contact (prolonged, intense, minimal)
- mannerisms, gestures
- general attitude (uncooperative, withdrawn, passive, inappropriate, guarded)
- attitude towards the interviewer (neutral, positive, negative, dismissive, ambivalent, hostile)
mood
(subjective data)
- good, happy, cheerful, euphoric, elated
- neutral, calm, peaceful
- depressed, hopeless, sad
- how are you feeling today
- what word would you use to describe your mood
- do you experience highs and lows
- is there any pattern to these mood changes
- suicide/self-harm risk assessment
- what is your mood on a scale from 0-10
affect
(objective data)
- physical manifestation that matches emotional expression
- observe emotional expression through physical expression (facial)
- want to measure congruency
- euthymic (neutral, nether happy or sad)
- note range of affect, appropriateness to context/situation, & congruency with stated mood
speech
(objective)
- physical manifestation of voice
- rate (average, slow, pressured)
- volume/tone (loud, soft)
- spontaneity/hesitant
- characteristics (accent, language)
- response time (latency)
- speech production (incoherent, pressured, muttering, slurred)
thought form
how the thoughts are organized & how they present thoughts
thought process
flow of conversation and quality of thoughts
- “how” the person is thinking, it is thoughts are formed and dif they are easy to follow or not
- can only be determined through the patient’s speech and how they describe thinking
examples of thought process
- logical, organized, goal-directed
- illogical, disorganized, non-sensical
- racing thoughts
- loose associations, tangential, flight of ideas
- thought blocking or slow, hesitant
- neologisms (inventing new words)
loose associations
- sentences maintained
- connection b/w ideas is unclear or nonsensical
tangential
- tight linkage b/w ideas
- sentence structure maintained
- does not address the point
flight of ideas
- sentences are maintained
- ideas remain connected
- rapid and frequent shifts in topic
thought content
- “what” the client is thinking about
- what topics they are spending their time thinking about
- looking for bothersome thoughts, preoccupations, or symptoms of psychosis = delusions
(objective & subjective)
perception
experiencing the environment and recognizing or making sense. of the stimuli received
aspects of perception
- hallucinations: auditory, visual, gustatory, olfactory, somatic
- command hallucinations
- illusions
- assess content of hallucinations, client’s interpretation/extent of beliefs in them being real, clien’ts reaction
positive symptoms
added
- any change in behaviour or thoughts, such as hallucinations or delusions
negative symptoms
taken away
- where people appear to withdraw from the world around then, take no interest in everyday social interactions, and often appear emotionless and flat.
cognitive functioning
- MMSE/folstein
- LOC (alert, drowsy)
- orientation
- concentration & attention
- memory (short-term, recent, remote)
- intellectual capacity/knowledge
- abstraction/concrete
insight
- awareness of situation, context
- recognition of illness, need for help
- understanding of factors contributing to illness
- motivation to work on identified problems
- stated as “full, partial, limited, impaired, none”
judgment
- behavioural manifestation of insight
- process one uses to reach a decision or take action
- ability to consider the pros & cons of decisions/choices
- “poor judgment” may be demonstrated by impulsivity, engaging in actions w/ damaging consequences
risk assessment: risk of self
- self harm & suicide are not same = assess BOTH
- when do we ask:
1. routinely ask during initial assessment & periodically throughout treatment process
2. when a change in behaviour is noted that may indicate elevated risk
3. following a major stressor
4. when we get “clues” that the client may feel hopeless or be experience suicidal thoughts - consider: suicidal thoughts, plans, intent, means, impulsivity, risk & protective factors
- suicide risk assessment tools can inform level of risk
suicide risk factors
- age
- sex
- history of psych disorder
- current psych diagnosis
- characteristic symptoms: hopelessness, anger, depression, guilt, anxiety
- previous history of suicidal behaviour
- history of abuse, trauma
- substance use
- situational risk factors & life stressors (interpersonal conflict)
- family history of suicide & psych disorders
- living alone
- social relationship problems (isolation, lack of support)
- access to lethal means
- physical health issues
individual protective factors for suicide
- strong sense of competence
- sense of purpose
- effective interpersonal skills
- effective problem-solving skills
- adaptive coping skills
- self-understanding
- optimistic outlook
- religious affiliation
work protective factors for suicide
- sense of accomplishment
- positive peer support and colleague relationships
- supportive, non-punitive work environmental
- professional development opportunities (career development, stress management)
- core values are present in the workplace (integrity, honesty)
- access to employee assistance programs
family protective factors for suicide
- sense of responsibility to family
- relationships characterized by warmth & belonging
community protective factors for suicide
- opportunities to participate
- affordable, accessible supportive resources
- hope for the future
- community self-determination & solidarity
BCCNM
- governing body, protects the public, issues your license
regulation of bccnm
- registration
- education
- standards/ethics
- inquiry and discipline (complaints/repercussions)
- interprofessional collaboration
duty to report
- if you have knowledge of another nurse who may be impaired, impaired practice (deteriorating mental health, taking substances, doing inappropriate things-sexual misconduct), you have duty to report this to college
documents of bccnm
- code of ethics (acceptable behaviour)
- scope of practice (tasks you can physically perform, restricted, practice, delegation)
- 5 professional standards (broad expectations)
- standards of practice
privacy & confidentially
- only access information when you need it
- only give information that is needed
- only disclose information to the appropriate people
purpose of bccnm
mandate is to protect the public
5 professional standards
- therapeutic relationships
- professional ethical practice
- leadership and collaboration
- competent, evidence informed practice
- professional responsibility
psychosocial rehabilitation (PSR)
- mental health treatment philosophy or approach that promotes resilience, personal recovery, full community integration, and a sense of purpose and meaning for those who have been diagnosed with any mental health condition and/or addiction issue
development of PSR: historical factors & influences
- focus on community reintegration required shift in focus from pharmacology & therapy to life skills required to function in the community
first principle of PSR: douglas college
- PSR practitioners convey hope & respect, and believe that all individuals have the capacity for learning and growth
second principle of PSR: douglas college
PSR practitioners recognize that culture and diversity are central recovery, and strive to ensure that all services and supports are culturally relevant to individuals receviing services and supports
third principle of PSR: douglas college
PSR practitioners engage in the processes of informed and shared decision-making and facilitate partnerships with other persons identified by the individual receiving services and supports
fourth principle of PSR: douglas college
PSR practices build on strengths and capacities of individuals receiving services and supports
fifth principle of PSR: douglas college
PSR practices are person-centered; they are designed to address the distinct needs of individuals, consistent with their values, hopes and aspirations
sixth principle of PSR: douglas college
PSR practices support full integration of people in recovery into their communities, where they can exercise their rights of citizenship, accept the responsibilities and explore the opportunities that come with being a member of a community and a larger society
seventh principle of PSR: douglas college
PSR practices promote self-determination and empowerment. all individuals have the right to make their own decisions, including decisions about the types of services and support they recieve
eighth principle of PSR: douglas college
PSR practices facilitate the development of personal support networks by utilizing natural supports within communities, family members as defined by the individual, peer support initiatives, and self and mutual-help groups
ninth principle of PSR: douglas college
PSR practices strive to help individuals improve the quality of all aspects of their lives, including social, occupational, educational, residential, intellectual, spiritual and financial
tenth principle of PSR: douglas college
PSR practices promote health and wellness, encouraging individuals to develop and use individualized wellness plans
eleventh principle of PSR: douglas college
PSR services. andsupports emphasize evidence-based, promising, and emerging best practices that produce outcomes congruent with personal recovery. PSR programs include program evaluation and continuous quality improvement that actively involve persons receiving services and supports
twelfth principle of PSR: douglas college
PSR services and supports must be readily accessible to all individuals whenever they need them; these services and supports should be well coordinated and integrated as needed with other psychiatric, medical, and holistic treatments and practices
PSR is what kind of approach
recovery
recovery means
living a satisfying life despite illness
- process or journey rather than outcome
recovery principles
hope, dignity, self-determination, responsibility
recovery movement attributed to
individuals with mental illness themselves considered a grassroots movement with a focus on advocacy
PSR, recovery and community mental health models
- ACT/ACM/ICM
- ACSS
- clubhouse programs
- residential programs
- housing first models
documentation is
- any written or electronically generated information about a client that describes the care or service provided to that client
- nursing action that produces a written account of pertinent patient data, nursing clinical decisions and interventions, and patient responses in a health record
key purposes of documentation
- communication
- safe and appropriate nursing care
- professional and legal standards & ethical
- accurate & thorough documentation important
professional standards = 2: competent, evidence-informed practice
- documents the application of the clinical decision-making process in a responsible, accountable and ethical manner
- applies documentation principles to ensure effective written/electronic communication
legal issues with documentation
- client’s record is a permanent, legal document
- may be used to provide evidence in court or coroner’s inquests
- nurse must clearly document all nursing care given, that care decisions were based on assessment and that the nurse continues to monitor, document, and report patient responses
in court….
care not documented is care not given
ethical issues in documentation
- protects the confidentiality of all information gathered in the context of the professional relationships
- practices within relevant legislation that governs privacy, access, use
- checking that computer screens aren’t visible, charts aren’t open or out
how do you keep records confidential
- computer passwords = log out when finished
- be mindful of screens & papers = may be viewable to others
- be aware of agency policies (documenting sensitive information = abuse)
- ensure all written documentation is in secured area, not accessible to clients, family members
- RPN to safeguard the privacy, security and confidentiality of health records
documentation principles
- only document care u personally provided
- only use agency-approved abbreviations
- never use pencil, only black pen
- document ASAP, in chronological order, never prior to giving care
- follow proper protocol of errors, no erasing or white out
- documentation must be clear, concise, factual, objective, timely and legible
- do not leave any blank spaces or lines
- RPN’s must add their signature and designation in clear, legible manner
common documentation forms
- initial assessment/admission forms
- nursing care plan
- flow sheets
- nursing notes
- interdisciplinary notes/history
- kardex
- incident reports (not part of health record)
kardex purpose
to make information readily available (not a legal document)
content of kardex
- pertinent info
- daily treatments (dressings)
- diagnosis procedures (blood work)
- allergies
- specific data (diet, assistance with transfer)
- diagnosis/goals
- mental health status (certified, passes)
- belief shift summary
what do we chart
- status & health concerns
- changes in status: MSE
- nursing care, interventions
- completeness (reflect nursing process)
- appropriateness (significant to assessment and care)
- advocacy by nurse on behalf of client
- chart client responses and evaluate the effectiveness of the care provided
- effectiveness of medications and prn medications
narrative charting notes
written chronologically in paragraph form in progress notes
problem-orientated/charting by exceptions - DARP, SOAP(IE)
focuses on documenting only deviations from the norm, narrative format; often seen with checklist flowsheets
source oriented medical records
each discipline writes in a separate section of the chart (history: dr note, interdisciplinary team: physio, nursing: nursing notes)
what does darp stand for
data, action, response, plan
managing late entries
Documenting the time of entry and the time the care was provided and writing “late entry” after the last recorded note
verbal reports
- state client’s name, medical diagnosis, changes in nursing assessment, vital signs related to baseline, significant lab data
- have chart ready to give any further info needed
- think about what the staff needs to know about the patient in order to work safely with this patient
purpose of incident reports
document unusual, unanticipated occurrences as a risk management tool. internal quality control only
aspects of incident reports
- identification of client by name
- date, time and place of incident
- description of facts of incident
- incorporation of the client’s account of incident
- identification of all witnesses
- identification of any equipment by number any medication by name and dosage
health professions act
- umbrella legislation that provides a common regulatory framework for health professions
- gives bccnm its mandate and powers
- regulations are created by gov for each individual health profession governed under act. each regulation defines reserved titles, contains a statement about scope of practice and outlines a set of restricted activities describing what members of that profession are authorized to do
- bylaws set out details of operation of organization: duties and responsibilities of governing board, committees and the registrar; qualifications for registration and licensing; the regulation of professional conduct and ethics and fee schedules
relevant legislation
- access to information act (federal)
- E-health act (provincial)
- freedom information and protection of privacy act (provincial)
- personal information protection act (provincial)
- personal information protection and electronic documents act (federal)
- privacy act (provincial)
-mental health act (provincial
FOIPPA
dictates how public bodies collect, store, and share information
implications for healthcare
confidentiality & continuity of care
purposes of FOIPPA are. tomake public bodies more accountable to the public and to protect personal privacy to:
- giving public right to access to records
- giving individuals right of access to, & right to request correction of personal information about themselves
- specifying limited exceptions to the rights of access
- preventing the unauthorized collection, use or disclose of personal information by public bodies
- providing for an independent review of decisions made under this act
consistent purpose (continuity of care)
can share information with others if that information is being shared for the same reason it was collected - to offer health care
FOIPPA exceptions
- disclosure harmful to individual or public safety
- disclosure harmful to personal safety
FOIPPA public interest
information must be disclosed if best interest of public (safety concerns, request made)
e health act attempts to
balance the goal of giving citizens access to their health records and medical information, while protecting privacy through electronic records
advantages of e records
- security of info: allows for a record to be kept of who has accessed information
- reduces likelihood of errors caused by misinterpretation of written material
- more efficient, allowing timely access
- promotes more effective communication and access between healthcare agencies & organizations
disadvantages of e records
documents are now “tic boxes” so MSE not helpful
privacy
right of individuals to determine for themselves when, how, and to what extent information about themselves is communicated to others
confidentiality
ensuring that the personal and health information belonging to another individual is kept private, safe from access or use by or disclosure to people who are not authorized to have the information
designed facility
place that can accept involuntary patients (psych ward)
section 20
voluntary hospitalization
voluntary admissions uder the mental health act requires the person to
request admission using form I, request for admission
- physician & director must agree to person’s admission
what other form is required for admit someone for voluntary admission
form 2 (consent for treatment)
important aspect for voluntary admission
may discharge themselves at any time - just like no-psych patients admitted to a hospital under hosptial act
3 methods for involuntary admissions
- medical certificate (section 22; form 4)
- police intervention (section 28 (1))
- judge’s order (section 28 (3); forms 9 & 10)
medical certificate aspects
- 1 medical certificate (form 4) detains for 48 hrs
- valid form 4 provides authority for anyone to take individual to designated facility
- second form 4 must be completed by different physician within 48 hrs of admission to further admission
- failure to do so results in patient being discharged or admitted as voluntary patient
- second form 4 valid for mouth
- patient should be informed when form 4 certificates are completed & read patients their rights
police intervention
- section 28 gives police authority to apprehend person & take them to physician for examination
- do not mean arrested
- criteria used by police different than physicians
- police must be satisfied on the basis of personal observation & info received from other that the person has mental disorder & is acting in manner that is likely to endanger their wn safety or saety of others
- “safety” element is higher standard to meet than the crtieria used by physician
order by judge
- section 28 (3)
- anyone who reason to believe person has a mental disorders & meets criteria for involuntary admission according to section 22 can apply to provincial judge to have person apprehended for assessment by physician
- form 9: application for warrant (apprehension of person w/ apparant mental disorder for purpose of examination) completed by family or friends
- if judge satisfied the judge issue warrant under section 28 - form 10 = giving police authority to apprehend
extended leave (form 20)
involuntarily treated in community, discharged from hospital but still have t follow involuntary rules
