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71 Cards in this Set
- Front
- Back
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Who sets the standards of care for patients in the mental health setting?
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American Nurses Association
The American Psychiatric Nurses Association, International Sociaety of Psychiatric-Mental Health Nurses |
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What methods should be used to assess clients?
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observation
interviewing physical examination collaboration |
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Alert
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the client is responsive and able to fully respond tby opening her eyes and attending to a normal tone of voice and speech. Answers questions spontaneously and appropriately
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Lethargy
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the client is able to open eyes and respond but is drowsy and falls asleep readily
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obtundation
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the client needs to be lightly shaken to elicit a response, but may be confused and slow to respond
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stupor
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requires painful stimulation to elicit a brief response. may not be able to respond verbally
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Coma
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no response with repeated painful stimulation
* abnormal posturing *decorticate rigidity *decerebrate rigidity |
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Mood
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provides information about the emotion that is felt
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affect
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an objective expression of mood
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2 types of memory
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recent
remote |
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Mini-Mental state examination includes
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orientation to time and place
attention span ability to calculate registration and recall language |
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Glasgow Coma Scale
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eye verbal and motor response is evaluated and a number value based on that response is assigned. 15- alert and responding, 3- comatose
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what manual is the diagnostic tool for patients with mental disorders?
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the DSM-IV
dianostic and statistical manual of mental disorders |
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What system does the DSM-IV use
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the axial system
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Axis I
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all mental health diagnosis except for those in Axis II
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Axis II
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any personality disorder diagnosis and mental retardation
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Axis III
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any general medical dianosis
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Axis IV
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pertinent psychosocial problems and problems that may affect diagnosis, treatment and prognosis of mental disorders
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Axis V
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global assessment of functioning: an assessment of present and past year functioning that rates the client's level of functioning in the areas of work performance, social abilities and psychological ability on a scale of 1 to 100
80-100-->normal or near normal 60-80--> moderate problems <40--> serious problems scores are present/past year. ex: 50/80. current score is 50, last year it was 80 |
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Counseling
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using therapeutic communication skills
assisting with problem solving crisis intervention stress management |
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Millieu Therapy
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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 the appropriate activities |
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Promotion of Self Care activities
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offering assistance with self care tasks
allowing time for the client to complete self care tasks setting incentives to promote client self care |
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psychobiological interventions
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administering prescribed medications
providing teaching to the client/family monitoring for side effects and effectiveness of therapy |
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Cognitive and behavioral therapies
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modeling
operant conditioning systematic desensitization |
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Health Teaching
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teaching social and coping skills
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Health Promotion/Maintenance
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assisting the client with cessation of smoking
Monitoring other health conditions |
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Case management
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coordinating holistic care to include medical, mental health and social services
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What does the acute care setting provide patients?
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intensive in patient treatment
stability that promotes return to society interdisciplinary team facilities may be privately or state owned case management and assistance in transition to community SP DC |
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what types of care sites are including in the community setting of care?
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clinics, schools, daycare centers, partial hospitalization programs, drug and alcohol treatment facilities, forensic settings, psychosocial rehab, telephone crisis counseling centers,home health care
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what does a nurse do in the community care setting?
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stabilize or improve a client's mental functioning within a community and teach support and make referrals in order to promote positive social activities
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criteria justifying admission to an acute care facility include
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a clear risk of the clients danger to self or others
the failure of community based treatment a dangerous decline in the mental health status of a client undergoing long term treatment a client having a medical need in addition to a mental illness |
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goals of acute mental health treatment
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prevention of the client harming self or others
stabilizing mental health crises return of clients who are severely ill to some type of community care |
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who is included in the interdisciplinary team?
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nurses, mental health technicians, psychologists, psychiatrists, other general health care providers, social workers, counselors, occupational and other specialty therapists and pharmacists
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Nursing role in an acute care setting includes?
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overall management of the unit, including client activities and therapeutic Millieu
Assuring safe administration and monitoring of all client medications implementation of individual client treatment plans, including client teaching, documentation of the nursing process for each client, managing crises as they arise |
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Primary Prevention
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promotes health and prevents mental health problems from occurring
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Secondary prevention
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focuses on early detection of mental illness
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Tertiary Prevention
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focuses on rehabilitation and prevention of further problems in clients previously diagnosed
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partial hospitalization programs
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provide intense short-term treatment for clients who are well enough to go home and have responsible person at home to provide support and a safe environment
certain detox programs are specialized for of partial hospitalization for the client who requires medical supervision, stress management, addiction counseling, and relapse prevention |
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Assertive Community Treatment (ACT)
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includes nontraditional case management and treatment by an interdisciplinary team for acaseload of clients with severe mental illness whoare noncompliant with traditional treatment
ACT helps to reduce reoccurrence of hospitalizations and provides crisis intervention, assistance with independent living and information regarding resources for necessary support services |
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Community mental health centers
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provide a variety of services including:
educational groups medication dispensing programs individual counseling programs |
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Psychosocial rehabilitation
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structured range of programs including:
residential services day programs for older adults for whom care is provided |
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Home Care
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provides mental health assessments, interventions, and family support in the clients own home. this implemented most often for children, older adults and clients with medical conditions
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General Adaptation Syndrome (GAS)
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the body's response to an increased demand. the first stage is the initial adaptive response, also known as the fight or flight mechanism. if stress if prolonged, maladaptive responses can occur
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what is stress management
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a persons ability to experience appropriate emotions and cope with stress
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factors that affect stress response
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age, gender, culture, life experiences, lifestyle
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protective factors that increase resilience to resist the effects of stress
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physical health, strong sense of self, religious or spiritual beliefs, optimism, hobbies, satisfying interpersonal relationships, strong support systems, humor
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Cognitive reframing
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the client is helped to look at irrational cognitions in a more realistic light and to restructure those thoughts in a more positive way
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relaxation techniques
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meditation, guided imagery, breathing exercises, progressive muscle relaxation, physical exercise
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biofeedback
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assist the client to gain voluntary control of such autonomic functions as heart rate and blood pressure
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assertiveness training
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client learns to communicate in a more assertive manner in order to decrease psychological stressors
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Grief
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the inner emotional response to loss and is exhibited in as many ways as there are individuals
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Bereavement
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includes both grief and mourning (the outward display of loss) as an individual deals with the death of a significant individual.
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Advanced directives
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legal documents that direct end-of-life issues. include living wills and power of attorney for health care
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Living Will
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directive documents for medical treatment per a client's wishes
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Durable Power of Attorney for Health Care
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document that appoints an individual to make medical decisions when a client is no longer able to do so on his own behalf
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Types of loss
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necessary loss, actual loss, maturational loss, situational loss
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necessary loss
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part of the cycle of life, anticipated but may be intensely felt
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actual loss
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any loss of a valued person or item
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perceived loss
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any loss defined by a client that is not obvious to others
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maturational loss
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losses normally expected due to the developmental processing of life
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situational loss
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unanticipated loss caused by an external event
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Kubler-Ross's five stages of grief
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denial
anger bargaining depression acceptance |
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Wordens four tasks of mourning
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Task I: accepting inevitability of loss
Task II: using coping mechanisms to experience the emotional pain of the loss Task III: changing the environment to accommodate the absence of the deceased Task III: changing the environment to accommodate the absence of the deceased Task IV: readjusting emotional ties to new individuals, and moving thoughts about the deceased to a less prominent place in everyday thoughts |
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Dysfunctional Grieving Risks
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being dependent upon the deceased
unexpected death at a young age, through violence, or by a socially unacceptable manner inadequate coping skills or lack of social support Pre-existingmental health issues such as depression or substance abuse |
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Types of grief
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Normal grief, anticipatory grief, dysfunctional grief, disenfranchised grief
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who is included in the palliative care interdisciplinary team
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physicians, nurses, social workers, massage therapists, music/art therapists, music art therapists, touch/energy therapists
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When is hospice care initiated?
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when the patient is expected to live for 6 months or less
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Characteristics of discomfort
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pain, anxiety, dyspnea, nausea or vomiting, dehydration, diarrhea or constipation, urinary incontinence,inability to perform ADL's
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S/Sx's of approaching death
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Decreased LOC, Muscle relaxation, labored breathing, mucus collection in large airways, incontinence of bowel and or bladder, occurrence of mottling with poor circulation, nonreactive pupils, weak pulse and dropping blood pressure, cool extremities, preparation, decreased urine output, inability to swallow
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post mortem documentation includes:
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person pronouncing death and at what time
consideration of and prepartion for organ donation disposition of personal articles names of people notified and any decision made location of ID tags time the body left the facility and the destination |
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How can nurses cope with client loss?
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attending the client's funeral
communicating in writing to the client's family attending debriefing sessions with colleagues using stress-management techniques talking with a professional counselor |
