Module 5 Mental Health Flashcards
describe a comprehensive assessment
-comprehensive= complete health history and physical examination where they consider psychological, spiritual, emotional, social, ethnic and cultural dimensions of health
• Evaluates how it affects individual’s daily living
• Purpose- develop holistic understanding of individuals problems/needs as well as strengths and resources
-May take days/weeks to complete
describe a focussed assessment
- focussed= collection of specific information about a particular need, problem, or situation and may involve evaluation of such things
- Briefer and more present oriented
what are the factors that depend on the type of assessment?
- type of assessment required depends on two factors:
1. Immediate needs of client and practice setting
2. Determined by the setting he or she works
what are the benefits of interprofessional practice?
• Reduced lengths of hospital stay
• Improved quality of life for patients/clients and families
• Improved access to care
• Enhanced patient/client safety
-Improved recruitment and retention of health care professionals
what does a psychiatric mental health nursing assessment assume?
that humans are whole, integrated begins who live in constant and reciprocal relationship with their physical and social environments and that individuals act and react to the meanings they assign to events and experiences, rather than to the events or the experiences themselves
what are the two common approaches to documentation?
-source-oriented documentation- each discipline is assigned a section of the client record (eg. nurses/physician notes)
• Identifies discipline but tends to fragment the data (and therefore antithetical to holistic care)
-problem-oriented documentation- everyone involved with the care of an individual makes entries in the same section of record.
• Facilitates interdisciplinary collaboration
-Also keeps team members oriented toward the clients goals, needs, and problems
what is part of the psychological domain?
- responses to mental health problems
- mental status
- behaviour
- self-concept
- stress and coping
- risk assessment
- PMH disorders- clinically significant patterns of behaviour or emotions that are associated with some levels of distress, suffering, or impairment in one or more areas such as school, work, social and family interactions, or the ability to live independently
- mental health and mental illness can simultaneously coexist within the same person
what is the mental status examination?
- a systematic assessment of an individuals appearance, affect, behaviour, and cognitive processes
- reflects a snapshot of examiners observations/impressions at the same time of interview to evaluate developmental, neurologic, and psychiatric disorders
define emotion, mood, affect, and speech
-emotion- individuals experience of a feeling state
-mood- pervasive and sustained emotion that colours the person’s perception of the world. Mood is what the individual reports about their own emotional state
-affect- individuals emotional responsiveness during the interview
-speech is described in terms of its quantity, rate and fluency of production, and quality
(quantity=talkative etc, rate= slow, hesitant, fast etc, fluency= apparent ease with speech, quality= monotone, whispered etc)
define perception
-perception- complex series of mental events involved with taking in of sensory info from the environment and the processing of that info into mental representations. Ex. Hallucinations
describe the thought process
- thought process is the manner in which thoughts are formed and expressed
- goal-directed flow of ideas, symbols, and associations initiated by a problem or task and leading toward a reality-oriented conclusion
what are the 3 factors that assessment takes into account?
risk factors, protective factors, and promotive factors
what is a risk factor?
-risk factors= those characteristics, conditions, situations, and events that increase individuals vulnerability to threats to safety or well-being
what is a protective factor?
-protective factors= attributes or conditions of an individual, family and/or community when present reduces, mitigates, or eliminates risk
what is a promotive factor?
- promotive factors= conditions or attributes of individuals, families, and/or communities that actively enhance well-being
- taken together, protective/promotive factors increase positive outcomes even in the face of risk/adversity
what does nursing interventions depend on?
-NI vary depending on nature of current problems, the status and severity of the illness, and individuals situation. Eg. Physical interventions: monitoring vital signs and neurologic functioning- necessary for someone who is being detoxified
what is the level of withdrawal used to determine?
used to determine most appropriate dose of pharmacotherapy-assisted symptom- triggered detoxification management
what is the withdrawal measured by?
a rating scale, clinical institute withdrawal assessment for alcohol (CIWA-R)
how does the CIWA work?
the higher the rate on scale, the greater the withdrawal symptoms
describe a minor withdrawal?
anxious, may experience nausea, vomiting, sweating, hypertension etc. Symptoms appear 6-12hrs after last sip
describe a intermediate withdrawal?
experience symptoms from minor withdrawal in addition to: seizures, dysrhythmias and/or hallucinosis. Grandmal and seizures typically occur 12-72hrs after. Remain oriented and alert
describe a major withdrawal (delirium tremens)
severe agitation, psychomotor and hyperactivity. Global confusion, disorientation, and auditory visual or tactile hallucinations. Tend to occur 5-6days after severe, untreated withdrawal. Symptoms fluctuate and often more severe at night-sudden death can occur
what is a mental status exam overview?
-A tool to guide data collection
•Includes objective and subjective data
•Data collected by formal & informal interview and observation
what are the developmental changes on MSE for children?
- 3-5 years: development of language and cooperative play
- 6-7 years: school readiness/thought processing develops
describe mood and affect in terms of which one is subject. and which is object.
Mood= subjective (individual response) Affect= objective
is speech subjective or objective?
both
is thought content subjective or objective?
subjective
is thought process sub or ob?
objective
is cognition objective or subjective?
objective (how well their cognition is intact based on how well they answer questions)
is socialization and interpersonal relationships objective or subjective?
objective cause you’re assessing interactions with others
what are the developmental changes on MSE for adolescents
- increased risk taking and greater ability to process abstract thought
- higher risk of intentional harm/homicide
- very scary time when teenagers don’t have a lot of control over their behaviour
- higher risk of mental health problems
- fear is often manifested as aggression
- half of the diagnosable mental health disorders begin by age 14
- vulnerable populations to mental health problems: aboriginal, immigrants, homeless, or within sexual minority
what are the developmental changes on MSE for adulthood?
- social isolation
- debt incurred from education
- middle age brings confidence and adaptability skills
- work demands
- biological changes (menopause etc)
- more vulnerable to distraction (because they have to multitask- harder to concentrate)
what are the developmental changes on MSE for older adulthood?
- aging leaves mental health intact but things simply slow down a bit
- loss of loved ones
- decreased in income
- changes in daily routines with retirements or loss
- sensory perception changes can impact mental health (vision or hearing loss)
what ages have the highest rates of suicide? and what is the most common illness?
40-59 and depression is most common
is suicide more common in males or females?
3x higher for males than females
what type of questions do you ask for the assessment?
- their intent (to die or to end pain?)
- do they have a plan?
- do they have an access to means? (the supplies they need to kill or dismiss the pain)
- how lethal is the means? (is it deadly)
- have they rehearsed it?
what does the acronym ISPATHWARM stand for?
I-Ideation: threatening to hurt or kill self
S-Substance Misuse
P-Purposelessness: no sense of purpose, no purpose in life
A-Anxiety
T-Trapped: feeling trapped
H-Hopelessness
W-Withdrawal: withdrawal from society, friends, family
A-Anger
R-Reckless
M-Mood: dramatic mood changes
what is ISPATHWARM for
its a questionnaire that patients fill out
what is the SADPERSONS scale?
a sheet for risk of suicide
what does SADPERSONS stand for?
S- Sex (male) A- Age (<19 or >45 years) D- Depression P- Previous suicide attempt E- Ethanol abuse R- Rational thinking loss S- Social supports lacking O- Organized plan N- No spouse S- Sickness
can the CIWA status of a patient change?
-CIWA status can deteriorate over time. Seem fine in the beginning and then decline throughout the day. Then will be fine again in the morning
list the alcohol withdrawal timeline
1: anxiety, insomnia, nausea, abdominal pain (8hrs)
2: high BP, increased body temperature (1-3 days)
3: hallucinations, fever, seizures, and agitation (1 week)
describe the scoring with the SADPERSONS scale
0–5: May be safe to discharge
6-8: Probably requires psychiatric consultation
>8: Probably requires hospital admission
what is delirium tremens?
• Rapid onset of confusion usually caused by withdrawal from alcohol. When it occurs, usually happens 3 days after withdrawal symptoms and lasts for 2-3 days
list symptoms of delirium tremens
• Symptoms include shaking, shivering, irregular heart rate, and sweating, hallucination, very high body temperature
Treated with benzodiazepines (valium/lorazepam)
what do you do for CIWA management?
- multivitamin and thiamine* supplement is important
- maintain fluid balance and support
- symptom control
- monitor for seizures
- monitor vitals for bp, temp etc
- blood work
what are the things you wanna look for during a MSE on a patient?
1) Appearance
2) Attitude/Psychomotor Behaviour
3) Mood
4) Affect
5) Speech
6) Perception
7) Thought Content
8) Thought Process/Form
9) Cognition
10) Insight and Judgment
11) Socialization & interpersonal relationship
what components are on the CIWA scale?
- nausea/vomiting (0-7)
- tremors (0-7)
- anxiety (0-7)
- agitation (0-7)
- paroxysmal sweats (0-7)
- orientation (0-7)
- tactile disturbances (0-7)
- auditory disturbances (0-7)
- visual disturbances (0-7)
- headache (0-7)
