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health assessment > week 4 > Flashcards

week 4 Flashcards

1
Q

what does a registered nurse do (organizing competencies)

A

-advocate
- coordinator
- communicator
- collaborator
- professional
- educator
- leader
- scholar
- clinician

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2
Q

types of objective neurological examination

A

-routine neurological screening assessment
- ongoing neurological observations
- a complete assessment

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3
Q

purpose of the routine neurological screening

A

identify any significant change in
- general neurological condition
- level of consciousness
- pupil size and reaction to light
- muscle strength and symmetry

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4
Q

in order to prep myself to do a neurological screening

A

-short fingernails
-hand hygiene

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5
Q

in order to prep the patient for a neurological screening

A

explanation
consent
position
comfort
privacy
- have them be in a semi-fowler position

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6
Q

in the general inspection during a neurological assessment

A

-note the person’s alertness
- posture
- facial features
- hygiene and grooming
- behaviour
- speech
- facial expressions (relaxed? agitated? maintain eye contact?)
- are movements coordinated
- note changes from previous assessment

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7
Q

the most important factor for neurological assessments

A

a change in the level of consciousness. If there is a change, a more detailed assessment using the Glasgow coma scale should be used. refer to medical practitioner

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8
Q

what shows that a person is fully alert

A
  • eyes open/ eyes open simultaneously when you approach
  • oriented to person, place and time
  • can follow verbal commands
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9
Q

how do you test pupillary response

A

-darken room
- have patient gaze into the distance which dilates pupils
-use pen light and move from the side to the middle of the face on each eye
- there should be a contraction when the light it shown on it
- note the size, shape, symmetry of each pupil

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10
Q

usual size of a pupil at resting

A

3-5mm

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11
Q

to establish a strength baseline

A

push against hand pressure against gravity (arms) and with resistance
-noting the symmetry in strength

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12
Q

for the neurological assessment you should document

A

-level of consciousness
- pupil size (in mm), shape, symmetry, reaction to light
- upper limb strength and symmetry
- lower limb strength and symmetry

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13
Q

factors that influence mental health

A

-internal emotional problems
- familial and social network
- community (health care systems, employment, education and housing)
- larger social issues (ex. poverty, racism and discrimination)

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14
Q

what is mental health determined by

A

socioeconomic, biological and environmental factors

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15
Q

define health according to the world health organization

A

health is a state of complete physical, mental and social well-being and not merely the absence of disease or infirmity

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16
Q

First nation mental wellness continuum…waht is mental wellness suppirted by

A

culture (spirit centred), language, elders, family and creation
-linked to inherent strength and positive wellbeing

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17
Q

define PTSD

A

a tramua or stressor-related disorder in which symptoms began or worsened after the experience of one or more traumatic events…depend on nature of the trauma and on characteristics of the individual and the environment

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18
Q

how does the WHO describe mental health

A

relative and ongoing state of well-being in which individuals realize their abilities, cope with the normal stresses of life, work productively and contribute meaningfully to the community
-find balance in all aspects of life

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19
Q

what are all factors of mental health referred to as

A

determinants of health

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20
Q

what is a mental disorder

A

-medical term for mental illness
- diagnosed in canada according to the DMS-5 (Diagnostic and Statistical manual of mental disorders)

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21
Q

mental disorders are depicted as constellations of co-occurring symptoms that…

A
  • alter thoughts, experiences and emotion
  • impair functioning
  • cause distress
  • difficult to keep interpersonal relationships and performing jobs
  • self destructive behaviour and suicide
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22
Q

factors for mental disorders

A

-physical environment
- genetics
- biology
- personality
- culture
- socioeconomic status
- life events

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23
Q

why is there a link between mental illness and comorbid conditions

A

mental illness complicates help-seeking, diagnosis and treatment and influences prognosis

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24
Q

concurrent disorders

A
  • co-occurrence of a mental health disorder and problematic substance use/substance use disorder is referred to as concurrent disorder
    ex. pathological gambling, problematic substance use, mental health disorders
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25
Q

for the treatment of individuals with concurrent disorders what could happen

A

-the experience of crisis
- relapse
- readmission to hospital

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26
Q

why is it important to have collaborative care for persons living with concurrent disorders

A
  • difficulty accessing appropriate services, resulting in unmet needs and poor outcomes
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27
Q

methods and components of mental health nursing assessment

A

-observation
- interview
- examination
- physical assessment
- collaboration with others

28
Q

what is mental status

A

emotional and cognitive functioning

29
Q

domains of mental status examination

A

-appearance
- behaviour (mood and affect, speech)
- cognition (consciousness, orientation, memory, attention and concentration, comprehension and abstract reasoning)
- thinking (perception, content, process, insight, judgement)

30
Q

define alert

A

-awake or readily aroused, fully aware of external and internal stimuli, conducts meaningful interpersonal interactions

31
Q

define lethargic (or somnolent)

A

not fully alert, drifts off to sleep when not stimulated

32
Q

obtended

A

transitional state between lethargy and stupor
-sleeps most of the time, difficult to arouse

33
Q

stupor or semicoma

A

-spontaneously unconscious, responds only to persistent and vigorous shake or pain, reflex activity persists

34
Q

coma

A

completely unconscious, no response to any external or internal stimuli. no motor response

35
Q

acute confusional state (delirium)

A

clouding of consciousness, disoriented, hallucinations and agitated

36
Q

indication for comprehensive mental health nursing assessment

A

-behaviour changes
- brain lesions (trauma, tumour and stroke)
- aphasia (caused by brain damage)
- symptoms of psychiatric mental illness

37
Q

developmental considerations for mental health in teens

A

-common disorders: depression,anxiety, ADHD, substance use
-suicide is the 2nd leading cause of death for canadian teens aged 15-19

38
Q

for mental health assessment for adults

A

-identification/biographical information
- reason for seeking care
- past health (illness, injury, hospitalization, chronic illness)
- family health history
- current health

39
Q

objective data-apperance examples

A

-posture
- body movements
- dress
- grooming and hygiene

40
Q

objective data- behaviour examples

A
  • level of consciousness
  • facial expression
  • mood
    -affect
41
Q

objective data-cognitive functions examples

A

-orientation
- attention span
- immediate memory
- recent memory
- remote memory
- new learning
-unrelated words test

42
Q

objective data- higher intellectual functions exmaples

A
  • insight and judgement
  • thought process
  • though content
  • perceptions
43
Q

what assessment is used for detecting 90% of mild cognitive impairments

A

Montreal cognitive assessment (MoCA)

44
Q

Functional Assessment activities of Daily Living (ADLs) examples

A
  • nutritional pattern
  • sleep/rest changes
  • activity/ mobility
  • elimination
  • interpersonal relationships and resources
  • self-esteem/ self-concept
  • spirituality
  • coping and stress management
  • smoking, drugs/alcohol, problem gambling
  • home and environmental hazards
45
Q

when assessing for risk assessment look for:

A
  • suicidal thoughts
  • assaultive or homicidal ideation
    -elopement risk
46
Q

for developmental consideration for adults and older adults (risk and guideline)

A

-age greatest risk factor for alzheimer’s disease
-older adult mental health assessment guidelines…new learning, set test and clock test

47
Q

abnormal findings: level of consciousness- examples

A

-alert
- lethargic (somnolent)
- obtunded
- stupor or semicoma
- coma
- acute confusional state (delirium)

48
Q

abnormal findings: mood and affect-examples

A
  • flat affect
  • blunted affect
  • depression
  • lability
  • elation
  • euphoria
  • anxiety
  • irritability
  • rage
    -ambivalence
49
Q

define addiction

A

compulsion and dependence

50
Q

what is the goal of abstinence and an example

A

aims to reduce the use of substances entirely
-AA (alcohol anonymous)

51
Q

what is the goal of harm reduction

A

aims to reduce the harms of substance use

52
Q

what are the 5 A’s for integrating knowledge of substance use in health assessment

A
  • Acquire knowledge
  • anticipate harm that may be caused by my practices, reactions and judgments
  • avoid social judgments about substance use
  • analyze organizational practices (ex. clinical assessment tools) and resources
  • approach patients respectfully
53
Q

what would increase stigmatization of drug use

A

viewing it as a choice…takes attention from the underlaying causes and factors influencing substance use

54
Q

Screening tools

A

TWEAK (tolerance, worry, eye-opener, amnesia and cutdown)
CAGE questionnaire (cutdown, annoyed, guilty, eye-opener)
- quick test for alcohol abuse and dependence
- initiates convo about alcohol use
- 4 straightforward yes/no questions
- doesnt distinguish past problem drinking from active present drinking

55
Q

when assessing for withdrawal

A

-understand that hospitalization can interrupt the usual pattern of substance use
- assessment and alertness is needed to manage it
- know the symptoms that are specific to diff types of substance use

56
Q

when documenting substance use

A

-be factual and nonjudgemental
- accuracy re:type of drug used, amount and route
- maintain patient confidentiality
-avoid stigmatizing language

57
Q

interpersonal violence examples

A

intimate partner violence, sexual assault, child maltreatment and elder abuse

58
Q

interpersonal abuse examples

A

-sexual assault
- child abuse
- intimate partner abuse
- elder abuse

59
Q

define sexual assault

A

sexual activity in the absence of voluntary agreement, including when consent has not been given, when the person is unable to give consent, or when a person initially consented then withdrew consent

60
Q

4 levels of sexual assault

A
  1. sexual assault that is forced sexual activity without physical injury
  2. sexual assault with a weapon or verbal threats to a third party
  3. sexual assault causing bodily harm
  4. aggravated sexual assault, which is formed sexual activity where the attacker seriously injuries, wounds, maims, disfigures or endangers life
61
Q

how abusers gain their power and control

A

-using intimidation
-using emotional abuse
- using isolation
- minimizing, deny and blaming
-using children
- using male privilege
- using economic abuse
- using coercion and threats

62
Q

key legislation for nurses for mental health care

A

-the mental health act
- the health care consent act
- the substitute decisions act
- the personal health information protection act
- Part XX.I of the Criminal code of canada

63
Q

what is the mental health act

A

criteria for voluntary, informal and involuntary admissions to specially designated psychiatric facilities and the management of psychiatric out-patients under CTOs
- protects rights of psychiatric patients-receives fromal right advice

64
Q

what is the health care consent act

A

-rules for determining capacity in 3 key areas: treatment decisions, admission to care facilities, personal assistance services
- rules for getting informed, voluntary consent from the patient or their SDM (substitute decision maker)

65
Q

what is the substitute decisions act

A

-legal framework for granting power of attorney for personal care or property which allows capable individuals to appoint someone to act on their behalf during a period of incapacity
- important to the MHA and HCCA

66
Q

what is the personal health information protection act

A

-governs the collection, use and disclosure of personal health info

67
Q

what is Part XX.I of the criminal code of canada

A

-governs the assessment, detention and release of persons who have come into contact with the criminal justice system as a result of a mental disorder and who have been found either unfit to stand trial or, not criminally responsible on account of mental disorder

health assessment (4 decks)

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