Mental Health Concepts Flashcards
Coping mechanisms
Types of adapting
Assess pt ability to adapt to temp or permanent role changes
Adaptive and nonadaptive
Crisis intervention
Self harm or harm toward others
Defense mechanisms
Projection
Projection: project fault on others
Milieu
Where healing happens
Cope and communicate
Problem with saying WHY
Always non therapeutic
MSE
Mental status exam
Psychological equivalent of a physical exam that describes the mental state and behaviors of the person
It includes
subjective descirptions
Objective observations
Why do we do a MSE
Info for diagnosis
Assessment of disorder
Response to tx
Provides snapshot at a point in time
What do we need to know about the pt prior
Baseline
Components of the MSE (9)
Appearance
Behavior
Speech
Mood
Affect
Thought process
Thought content
Cognition
Insight/judgment
Assessment
Perform what as indicated
Can we use touch?
Respect what
Include what type of questions
Include who
Obtain what
Summarize and asl for what
Perform physical assessment as indicated
Touch can be utilized
Respect personal space if they dont want to be touched
Include questions r/t sleep, energy, appetite, depression, anxiety, mood, SI/HI
Include family
Obtain med history
Summarize and ask for feedback
Psychosocial hx
Perception of own health, beliefs about illness and wellness
Activity/leisure activites (how they pass time)
Use of substances and hx of it
Client stress level and coping ability
Coping strategies and support system
Cultural beliefs and practice
Assess their beliefs.
Assess cultural factors and how they can impact care
Nurse stay away from stereotyping and stigmatizing
Use trained interpreter
Spiritual and religious beliefs
Difference
Are they also the same
Assess what
Spirituality: internal values, sense of morality, views of purpose of life
Might not connect spiritual and religion views
Religion: according to an organized set of patterns of worship and rituals
Assess support system
MSE LOC
Alert
Lethargic: drowsy
Stuporous: requires pain stimuli to respond
Comatose
Decorticate rigidity: flexion
Decerebrate rigidity: extension
Physical appearance
Hygiene
Grooming
Nutritional status
Clothing choice
Looks older than their stated age
Behavior
Important to know
Examine what
Mood vs affect
Important to know baseline
Exam voluntary and involuntary body movements and eye contact
(Tremors, tics, ROM, rigidity, gait, agitation, restlessness)
Mood : emotion client is feeling
Affect: objective expression of mood (facial expression)
Mood
Definition
Place in what
Labile meaning
Prevalent emotional state pt tells you they feel
Placed in quotes
Labile=unstable (goes from smiling to crying)
Affect (types,range,congruency,stability,appropriateness)
Types:
euthymic (normal)
dysphoric(depressed, angry)
Euphoric (elevated, anxious)
Range:
Full (normal), contricted/blunted, Flat, labile
Congruency: does it match the mood
Stability: stabile vs labile
Appropriate to situation
Speech
Rate
Rhythm
Volume
Content
Thought process
Rate of thoughts and how they connect and flow
Normal: tight, logical, linear, coherent, goal directed
Abnormal: not clear, organized, coherent
Thought process examples:
Circumstantial
Tangential
Loose
Flight of ideas
Thought blocking
Perseveration
Word salad
Circumstantial: provides unneccesary detail but eventually gets to the point
Tangential: move from thought to thought never gets to point
Loose: illogical shifting between unrelated topics
Flight ideas: quickly moving from one idea to another
Thought blocking: thoughts are interrupted
Perseveration: repetition of words, phrases or ideas
Word salad: randomly spoken words
Delusions
fixed, false beliefs firmly held despite contradictory evidence
Control delusions
Outside forces are controlling actions
Erotomanic delusions
A person, usually of higher status, is in love with the pt
Grandiose delusion
Inflated sense of self-worth, power or wealth
Reference delusions
Something happening in the environment is about them
Ex: intials RAM thinking RAM trucks are trying tog to communicate with them
Persecutory delusions
Others are trying to cause harm
Hallucinations
False sensory perceptions
Auditory: most common
Visual
Tactile
Gustatory
Olfactory
***need to know if it is command hallucinations for safety
Illusions
Misperceive or misinterpret real stimuli
Ex: see phone cord and think its a snake
De-realization:
Altered perception of the enviornment
Environment feels strange
Depersonalization
Altered perception of the self
Feeling outside the body
Cognitive and intellectual abilities (4)
Assess:
Orientation to time, person and place
Memory
Ability to think abstractly: interpret cliche (a bird in the hand is worth two in the bush)
(Judgment) based on answers to hypothetical questions:
What would you do if there were a fire in your room?
Insight vs judgement
Insight:
Awareness of one’s own illness or situation
Judgement:
Ability to anticipate the consequences of ones behavior and make decisions to safeguard your well being
MMSE
SLUMS
Wong Baker FACES
MMSE:
Mini-mental state examination
SLUMS:
Saint Louis University Mental Status Exam
Wong Baker FACES:
Pain assessment
