Bakersfield College NURS B25 2021 ATIMental Health Review Guide

ATI Mental Health
LOC
 Alert: responsive, answer questions appropriately, opens eyes spontaneously.
 Lethargic: open their eyes, can answer questions but easily falls asleep.
 Stupor: barely responds to painful stimuli (like rubbing the patients’ sternum)
 Comatose: unconscious/does not respond to painful stimuli
 Decorticate: flexion/ internal rotation of upper extremities, joints and legs
 Decerebrate: neck/elbows extension, wrist and finger flexion

Torts: unintentional torts- negligence: forgetting to set the bed alarm for a patient who is at risk for
falling and falls out of bed.

Malpractice- giving the wrong medication to the patient, error that harms the patient.

Intentional torts:

Assault vs Battery:
 Assault is if you threaten someone, “If you do not take this pill, I will smack you.”
 Battery: when you actually hurt someone, “You actually act by smacking the patient.”
 False imprisonment: Nurse will purposely restrain the patient or give them a chemical to a pt.
for the nurse convenience, instead of doing alternatives techniques.

Six Ethical Principles
 Beneficence – Doing good by the patient, what is best for the patient. Making the patient feel
safe in the environment that their in.
 Autonomy- respecting their rights by what they decide for their health care. Clients making
decisions but the patient must accept consequences of those decisions.
 *Veracity- truthfulness “Being honest with the patient’s treatment”
 Justice- fair/equal rights for everyone.
 *Fidelity- being loyal to the patient, keeping promises.
 Non-maleficence: Doing No Harm

Legal Rights of the patients in Mental Health
 Pt has the right to refuse treatment even if they’re in a mental health facility.
 Pts confidentiality: HIPPA: cannot be released without the consent of the patient
 If someone calls the unit asking about the patient refer them to contact the patient’s
family regarding the patient well being
 Over hear a conversation in a public place: tell them to go have the conversation in a
private setting.
 Mandated that abuse is reported, with a child or an older adult.
 Our duty to warn third parties if they’re at risk for harm.

,Informed Consent: Provider:
 Communicate the purpose of the procedure
 Give a clear description of the procedure in the patient primary language.
 Explain the risks vs the benefits
 Other options in treating the condition

RN Role:
 make sure the provider gives this information to the patient.
 Pt is competent in receiving the information, they must be an adult or an emancipated
child, THERE CAN BE NO IMPAIRMENTS!
 If they do not understand the information then we do not answer the questions, have
the provider answer the questions.

Restraints:
 Physical- vest, belt, and mittens. LAST RESORT
 Chemical- sedative/antipsychotic medications
 Alternatives before restraints: verbal interventions, calm/quiet environment, diversions.
 Prescriptions must be written
 Write an order for restraints to be placed on patient. If the orders need to be renewed it has to
be renewed within 24 hours.


Care for the Patient:
 Assessing the patient vital signs q 15 mins
 Offer them food and fluid- Every hour
 Make sure they get the chance to toilet- Every hour
 Monitor vital signs.

Emergency Restraints Placed:
 get an order from the doctor within 15-30 mins
 Time limits: 18 and older: 4 hours, 9-17: 2 hours, 8 and under= 1-hour, extra documentation:
event that caused the restraints to be placed, alternative interventions that were attempted,
time treatment began, med administered, patient assessment including current behavior, v/s,
pain. Pts care provided: food, helping them to the bathroom.

Therapeutic Communication:
 *Always try to get more information from the patient. You never want to shut down
communication between you and the patient. *“Always go for tell me more response”
 Intrapersonal communication: self-talk, thinking thoughts, not verbalizing them.
 Interpersonal communication: one on one communication with another person.

,  Open ended questions: promote interactive discussions “Tell me more, can you share more
about x y,z
 Closed ended= when looking for a specific answer/ Medical History. Yes/no answers

Clarifying techniques:

Restating = repeating back the patient exact words

Reflecting= returning focus back to the patient

Paraphrasing = restating the patients’ feelings and thoughts to confirm what has been
communicated. “What I think I hear you saying is this”

Exploring= gathering more information about something that the patient has mentioned. “You
mentioned this can you tell me little more about that.”

General leads= allows the patient to guide the discussion

*Presenting reality= focus on what is actually happening to stop the hallucination, delusions,
faulty beliefs. “Must be really scary to hear voices can you tell me what their saying”

Offering self: demonstrates a willingness to spend time, and the nurse has a genuine concern.

Barriers:
 Do not offer personal opinions: Never say “ You should do this”
 Do not give advice
 Do not give false reassurance.
 *NEVER ASK WHY!
 Never offer value judgements
 Don’t do excessive questioning.
 Respond approvingly or disapprovingly
 Always stay neutral while talking. “ I know exactly how you feel” Never say this!

Best Practices when working with older adults:

Minimize distractions, discuss health in a private setting, face the patient when speaking, use a
low-pitched voice, in the beginning of the interview identify the concerns/needs of the patient,
limit the number of items on the questionnaire,* give the patient plenty of time to respond to
questions when gathering data*




Defense Mechanisms:
 *Repression: putting unacceptable ideas out of unconscious awareness. “ Pushing it out of your
mind and not thinking about it actively.
 Displacement: Substituting a different target, Ex: A person who loses his job at work but comes
home and destroys his son favorite toy.