411 Study Guide (From PP and ATI)
Intro To Mental Health Nursing:
- mental illness: collectively all diagnosable mental disorders or health conditions that are characterized by
alterations in thinking, mood, or behavior associated with distress and/or impaired functioning
- mental health: a state of well being in which the individual realizes his or her own abilities, can cope with
the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his
or her community.
DSM V: diagnostic and statistical manual of mental health disorders by the APA
- guides
- help ID nsg concepts
- to plan
- to implement
- to evaluate care
Mental Status Exam
- An assessment of an individual’s mental functioning at one point in time
- Consists of:
o Orientation (observed, inquired)
Name, place, date
o General Appearance (observed)
Does the person appear younger/older than age
Attitude
Clothing: appropriate for season?
Hygiene/Grooming
Facial Expression (affect)
o Behavior (observed)
Gait, abnormal movements, posture, rate of movements
o Mood and Affect (observed, inquired)
Observe Affect: appropriateness, range, stable/labile
Ask about mood
o Speech (observed)
Rate, flow, clarity, quantity
o Thought Content/Process (observed, inquired)
Assess through speech
Patterns: linear, circumstantial, tangential, neologisms, concrete/abstract
Concentration: can you spell WORLD backwards, count backwards from 7
Insight into illness: tell me how you came to be here?
Ability to think abstractly: a rolling stone gathers no moss
Delusions, obsessions, hallucinations, suicidality/homicidality
o Memory/Judgment
What would you do if your house caught fire?
Attention/concentration
Assess recent memory and remote memory
o Level of Consciousness
Therapeutic Communication
The purposeful use of communication to build and maintain relationships with clients, families, and
significant others
, Is goal oriented and directed at learning and growth promotion
Based on respect
Self analysis FIRST building block of therapeutic relationship/ “self talk” or intrapersonal communication
Facilitative Conditions
o Empathy
Understanding clients from their point of view
Purpose is to communicate a depth of understanding in such a manner that clients can
clarify their own self-understanding
o Respect and Warmth
Demonstrate by open posture, smiling, vocal qualities
o Concreteness
Seek specifics rather than vague generalities
o Genuineness
o Immediacy
o Unconditional Positive Regard
Accepting clients even though you may not accept their behavior
Phases of a Therapeutic Relationship:
o (Pre-Interaction)
(self awareness, explore your feelings thoughts and fears)
(know your own professional strengths and limitations)
(gather data about the pt when possible)
(plan for the first meeting with the pt)
o Orientation
Determine why the patient sought help (“chief complaint” in quotes)
Establish trust by establishing expectations and boundaries
Explore the patient’s ideas, thoughts, feelings and actions
Identify the patient’s problems
Mutually set goals with patient
Create a contract that outlines the nurses role and patient, purpose of relationship,
meeting location and time, conditions for termination, and confidentiality.
o Working
Explore relevant stressors
Promote development of insight
Encourage the patient to problem-sole
Teach or reinforce constructive coping mechanisms
Overcome resistance
Remind about termination
o Termination
Establish the reality of separation
Review the progress of therapy toward goals
Mutually explore feelings of loss, sadness
Boundaries:
- the appropriate degree of relatedness or separateness between nurse and client
- boundaries keep the nurse and client safe and communication healthy
- ego boundaries: mostly establishes in childhood. Personal identity, separate thoughts, preferences,
values distinct from others
- Boundary Blurring: outside of professional relationship
Intro To Mental Health Nursing:
- mental illness: collectively all diagnosable mental disorders or health conditions that are characterized by
alterations in thinking, mood, or behavior associated with distress and/or impaired functioning
- mental health: a state of well being in which the individual realizes his or her own abilities, can cope with
the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his
or her community.
DSM V: diagnostic and statistical manual of mental health disorders by the APA
- guides
- help ID nsg concepts
- to plan
- to implement
- to evaluate care
Mental Status Exam
- An assessment of an individual’s mental functioning at one point in time
- Consists of:
o Orientation (observed, inquired)
Name, place, date
o General Appearance (observed)
Does the person appear younger/older than age
Attitude
Clothing: appropriate for season?
Hygiene/Grooming
Facial Expression (affect)
o Behavior (observed)
Gait, abnormal movements, posture, rate of movements
o Mood and Affect (observed, inquired)
Observe Affect: appropriateness, range, stable/labile
Ask about mood
o Speech (observed)
Rate, flow, clarity, quantity
o Thought Content/Process (observed, inquired)
Assess through speech
Patterns: linear, circumstantial, tangential, neologisms, concrete/abstract
Concentration: can you spell WORLD backwards, count backwards from 7
Insight into illness: tell me how you came to be here?
Ability to think abstractly: a rolling stone gathers no moss
Delusions, obsessions, hallucinations, suicidality/homicidality
o Memory/Judgment
What would you do if your house caught fire?
Attention/concentration
Assess recent memory and remote memory
o Level of Consciousness
Therapeutic Communication
The purposeful use of communication to build and maintain relationships with clients, families, and
significant others
, Is goal oriented and directed at learning and growth promotion
Based on respect
Self analysis FIRST building block of therapeutic relationship/ “self talk” or intrapersonal communication
Facilitative Conditions
o Empathy
Understanding clients from their point of view
Purpose is to communicate a depth of understanding in such a manner that clients can
clarify their own self-understanding
o Respect and Warmth
Demonstrate by open posture, smiling, vocal qualities
o Concreteness
Seek specifics rather than vague generalities
o Genuineness
o Immediacy
o Unconditional Positive Regard
Accepting clients even though you may not accept their behavior
Phases of a Therapeutic Relationship:
o (Pre-Interaction)
(self awareness, explore your feelings thoughts and fears)
(know your own professional strengths and limitations)
(gather data about the pt when possible)
(plan for the first meeting with the pt)
o Orientation
Determine why the patient sought help (“chief complaint” in quotes)
Establish trust by establishing expectations and boundaries
Explore the patient’s ideas, thoughts, feelings and actions
Identify the patient’s problems
Mutually set goals with patient
Create a contract that outlines the nurses role and patient, purpose of relationship,
meeting location and time, conditions for termination, and confidentiality.
o Working
Explore relevant stressors
Promote development of insight
Encourage the patient to problem-sole
Teach or reinforce constructive coping mechanisms
Overcome resistance
Remind about termination
o Termination
Establish the reality of separation
Review the progress of therapy toward goals
Mutually explore feelings of loss, sadness
Boundaries:
- the appropriate degree of relatedness or separateness between nurse and client
- boundaries keep the nurse and client safe and communication healthy
- ego boundaries: mostly establishes in childhood. Personal identity, separate thoughts, preferences,
values distinct from others
- Boundary Blurring: outside of professional relationship
