Week 12 - Mental Health Flashcards
mental health
finding balance in all aspects of life; can vary over time across a continuum
mental disorder
constellations of so-occurring symptoms involving alterations in thought, experience, and emotion
mental health nursing assessment
methods:
observation
interview
examination
physical assessment
collaboration with others`
components of the health history interview
identification/biographical information
reason for seeking care
past health
- illness, injury, hospitalization; chronic illness
current health/review of systems
functional assessment
self-concept, self-esteem
interpersonal relationships and resources
coping and stress management
Nurse-patient relationship influenced by
-personal, socioeconomic and political factors.
-gender, age, sexual orientation, economic factors, cultural, historical and geographic elements
-poverty, income, education and neocolonial policies and practices
mental status examination
emotional and cognitive functioning
Domains A B C T
Appearance
Behavior
- mood and affect, speech
Cognition
- consciousness, orientation, memory, attention and concentration, comprehension and abstract reasoning
Thinking
- perception, content, process, insight, judgement
Appearance
posture
body movements
dress
grooming and hygiene
behavior
LOC
- Alert, oriented, drowsy, obtunded, stupor, coma, delirium
Facial expression
- smiling, frowning, fear, anger, surprise, disgust
Speech
- raised or muffled, fast, slow, articulation
Mood and affect
- flat, depressed, elated, euphoric, anxiety, fear, irritability, rage, ambivalences, inappropriate
cognitive functions
orientation
attention span
- do something that has three or more steps
immediate memory
- recall a statement you just made
recent memory
- 24-hour diet recall
remote memory
- ask a verifiable historic event
new learning
- four words e.g., apple, table, cow and penny
thought processes, content, and perceptions
Thought process:
1) Does this person make sense?
2) Logical – Goal directed, coherent, and relevant
Thought content:
-What person says should be consistent and logical ie. “Do you perform specific actions to reduce certain thoughts?”
Perceptions:
-Is the person aware of reality ie. Delusions- “Do you have any thoughts that other persons think are strange?”
objective data
sudden behavior changes
includes LOC
Aphasia
Suicide risk
risk assessment
Screen for suicidal thoughts
Screen for Assault or Homicidal Ideation
Screen for Elopement Risk
ASK:
Have you ever felt so blue that you thought of hurting yourself?
Do you have thoughts of hurting others?
Do you understand why you need to be in the hospital at this time?
abnormal findings
abnormalities of mood and affect
Flat affect (blunted affect)
Depression
Depersonalization
Elation
Euphoria
Anxiety
Fear
Irritability
Rage
Ambivalence
Lability
Inappropriate affect
knowledge of substance use applied in health assessment
health promotion
take patient’s and population’s context into account
trauma- and violence-informed care
minimize harm
relevant terms and documentation
Substance use / abuse:
American Psychiatric Association prefers the term “substance use disorder” in DSM-5
Substance use:
Preferred term over addiction, dependence, disorder, misuse
Confusing or Problematic Terms:
Addiction:
Generally refers to compulsion and dependence; disagreement over usefulness of term.
Dependence:
Used as a label for compulsive, out of control substance use.
Include
- type of substance used
- amount(s)
- route
- result of health history and physical assessment
screening tools - TWEAK
tolerance
worry
eyeopener
amnesia
Kcut Down
Used to identify WOMEN who are at risk for alcohol use problems
CAGE questionnaire
Cutdown
Annoyed
Guilty
Eye-opener
Quick test for alcohol abuse and dependence
Four straightforward questions with yes/no responses
Does not distinguish past problem drinking from active present drinking
Useful to initiate conversation about alcohol use
(Please note: This test will only be scored correctly if you answer each one of the questions.
Please check the one response to each item that best describes how you have felt and behaved over your whole life.)
Have you ever felt you should cut down on your drinking? __Yes __No
Have people annoyed you by criticizing your drinking? __Yes __No
Have you ever felt bad or guilty about your drinking? __Yes __No
Have you ever had a drink first thing in the morning to steady your nerves or get rid of a hangover (eye-opener)? __Yes __No
If client answers 2 or more “yes” responses, consider at risk for alcohol withdrawal.
assessing for withdrawal
Alcohol:
- insomnia, sweating, racing heart, tremors, nausea and vomiting, psychomotor agitation, anxiety, seizures (rarely hallucinations and perceptual disturbances). Can be life-threatening if not treated (cardiovascular collapse)
Sedatives
- anxiety, orthostatic hypotension, tremors of the hands, tongue and eyelids,
Nicotine
- vasodilation, headaches, irritability and nervousness,
Cannabis
- irritability, nervousness, sleep difficulty, decreased appetite, restlessness, depressed mood and physical symptoms such as discomfort.
Cocaine
- dysphoric mood, agitation, insomnia, or hypersomnia
Amphetamines
- as above
Opiates
- as above
5 A’s for integrating knowledge of substance use in health assessment
Acquire knowledge; replace erroneous assumptions
Anticipate harm that may be caused by your practices, reactions, judgements
Analyze organizational practices (e.g., clinical assessment tools) and resources
Avoid social judgement about substance use, such as seeing a person as “bad,” deviant, or morally weak
Approach patients respectfully
interpersonal violence
-always an abuse of power
-involves physical/sexual violence, psychological violence, or financial abuse within current/former intimate, marital or common-law relationships, and same-sex spousal relationships
-may include physical/sexual assault, verbal abuse, imprisonment, humiliation, stalking, denial of access to financial resources, shelter, or services
-can involve denial of access to children, family members
structural violence
refers to the harmful ways in which society is organized (the ways power is distributed) so that people are put at risk, such as through systemic discrimination based on:
- race/ethnicity, class ability, gender, and other social constructions,
- poverty sustained by economic arrangements and policies
- other policies that create vulnerabilities for some people
ecological model
helps nurses understand IPV in the wider context of society
