ATI MENTAL HEALTH (PSYCH) Study Guide Notes

Basic Mental Health Nursing Concepts (Chapter 1) Level of Consciousness  Alert – The client is responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. The client answers questions spontaneously and appropriately.  Lethargy – The client is able to open her eyes and respond but is drowsy and falls asleep readily.  Stupor – The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. She may not be able to respond verbally.  Coma – No response can be achieved from repeated painful stimuli. Abnormal posturing in the client who is comatose Decorticate rigidity – flexion and internal rotation of upper-extremity joints and legs Decerebrate rigidity – neck and elbow extension, wrist and finger flexion Physical Appearance observation of personal hygiene, grooming, and clothing choice. Behavior includes observation of voluntary and involuntary body movements, and eye contact. Mood – A client’s mood provides information about the emotion that she is feeling. Affect – A client’s affect is an objective expression of mood, such as a flat affect or a lack of facial expression Cognitive and intellectual abilities Collect data regarding the client’s orientation to time, person, and place. Check the client’s memory, both recent and remote. Immediate – Ask the client to repeat a series of numbers or a list of objects. Recent – Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission. Remote – Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother’s maiden name Check the client’s level of knowledge: For example, ask him what he knows about his current illness or hospitalization. 1 Collect data regarding the client’s ability to calculate. For example, can he count backward from 100 in serials of 7? Check the client’s ability to think abstractly. For example, can he interpret a cliché such as, “A bird in the hand is worth two in the bush”? The ability to interpret this demonstrates a higher-level thought process.  Perform an objective data collection regarding of the client’s perception of his illness.  Check the client’s judgment based on his answer to a hypothetical question. For example, how would he answer the question, “What would you do if there were a fire in your room?” His response to the question should be logical.  Collect data about the client’s rate and volume of speech, as well as the quality of his language. His speech should be articulate and his responses meaningful and appropriate. Mini-Mental State Examination Orientation to time and place Attention span and ability to calculate by counting backward by seven Registration and recalling of objects Language, including naming of objects, following of commands, and ability to write Glasgow Coma Scale This examination is used to obtain baseline data of a client’s level of consciousness, and for ongoing monitoring. Eye, verbal, and motor response is evaluated, and a number value based on that response is assigned. The highest value possible is 15, which indicates that the client is awake and responding appropriately. A score of 7 or less indicates that the client is in a coma. Mental Health Diagnoses The Diagnostic and Statistical Manual of Mental Disorders, 5th Edition (DSM-5)  is used as a diagnostic tool to identify mental health diagnoses. It is used by mental health professionals for clients who have mental health disorders.  Nurses use the DSM-5 in the mental health setting to identify diagnoses and diagnostic criteria to guide data collection; to assist with the identification of nursing diagnoses; to assist with the planning of care; and to implement and evaluate care. MENTAL HEALTH NURSING INTERVENTIONS Counseling: Using therapeutic communication skills › Assisting with problem solving › Crisis intervention › Stress management Milieu therapy: Orienting the client to the physical setting › Identifying rules and boundaries of the setting › Ensuring a safe environment for the client › Assisting the client to participate in appropriate activities Promotion of self-care activities: Offering assistance with self-care tasks › Allowing time for the client to complete self-care tasks › Setting incentives to promote client self-care Psychobiological interventions: Administering prescribed medications › Reinforcing teaching to the client/family about medications › Monitoring for adverse effects and effectiveness of pharmacological therapy Cognitive and behavioral therapies: Modeling › Operant conditioning › Systematic desensitization Health teaching › Encouraging social and coping skills 2 Health promotion and health maintenance › Assisting the client with cessation of smoking › Monitoring other health conditions Case management › Coordinating holistic care to include medical, mental health, and social services Knowledge of Understanding Mental Status Examination Counting backward by 7 is an appropriate technique to check a client’s cognitive ability Observing a client’s facial expression is appropriate when checking affect. Writing a sentence is an indication of language ability. Asking the client to repeat a list of objects is appropriate to check immediate, rather than remote, memory Mental Health Nursing Interventions (know all of theses) Assisting with systematic desensitization therapy is a cognitive and behavioral intervention Encouraging appropriate coping mechanisms is a counseling or health teaching intervention Evaluating for comorbid health conditions is health promotion and maintenance intervention Monitoring for adverse effects of medications is an example of a psychobiological intervention. Initial client interview Identify the client’s perception of her mental health status. Data collection is the priority action when taking the nursing process approach to client care. Identifying the client’s perception of her mental health status provides important information about the client’s psychosocial history. Basic Mental Health Concepts The DSM-5 is used as a diagnostic tool to identify: mental health diagnoses establishes diagnostic criteria for mental health disorders. diagnostic tool for the diagnosis of mental health disorders Nurses use the DSM-5 to assist in the planning of care, and to implement and evaluate care. Legal and Ethical Issues Chapter 2 Clients who have been diagnosed and/or hospitalized with a mental health disorder are  guaranteed the same civil rights as any other citizen  right to vote  right to refuse treatment  confidentiality  view written plan of care  human care and treatment  care with respect  freedom from harm, neglect and abuse 3 Ethical principles Beneficence › This relates to the quality of doing good and can be described as charity. Example: A nurse helps a newly admitted client who has psychosis feel safe in the environment of the mental health facility. Autonomy › This refers to the client’s right to make her own decisions. But the client must accept the consequences of those decisions. The client also must respect the decisions of others. Example: Rather than giving advice to a client who has difficulty making decisions, a nurse helps the client explore all alternatives and arrive at a choice. Justice › This is fair and equal treatment for all. Example: During a treatment team meeting, a nurse collaborates with the interdisciplinary team regarding whether or not two clients who broke the same facility rule were treated equally. Fidelity › This relates to loyalty and faithfulness to the client and to one’s duty. Example: A client asks a nurse to be present when he talks to his mother for the first time in a year. The nurse remains with the client during this interaction. Veracity › This refers to being honest when dealing with a client. Example: A client states, “You and that other staff member were talking about me, weren’t you?” The nurse truthfully replies, “We were discussing ways to help you relate to the other clients in a more positive way.”