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DSM-IV-TR Multiaxial System
- AXIS I - All Mental health diagnoses
- except those found in Axis II
- AXIS II - Any personality disorder diagnoses & mental retardation
- AXIS III - any general medical diagnoses (asthma, DM)
- AXIS IV - pertinent psychosocial problems & living condition
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CLIENT EVALUATION - Start the nursing process by collcting subjective data (psychosocial history) & obejective data (mental status exam)
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MENTAL STATUS EXAMINATION - Affect - Objective expression of Mood, such as flat affect (lack of Facial expression
- Cognitive & Intellectual Abilities:
- Orientation & Memory - remote, recent, immediate
- Ability to think abstractly
- Insight - objective assessment of the clients perception of the Illness
- Judgment - Based on the clients answer to a hypothetical question
- Thought Process - processing differences, such as rapid change of Topic (Flight Ideas)
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MENTAL HEALTH NURSING INTERVENTIONS
- Counseling - using therapeutic communication skills
- Milieu Therapy - Orienting the client to the physical setting
- Promotion of Self Care Activities: offering assistance with self care tasks
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INTENTIONAL TORTS
- False Imprisonment - confining a client to a specific area
- Assault - Making a threat
- Battery - touching in a harmful or offensive way
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ETHICAL ISSUES - ethical issues are philosophical ideas regarding right and wrong
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CONFIDENTIALITY - Client's right to privacy is protected by HIPAA
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RESOURCES FOR SOLVING ETHICAL CLIENT ISSUES - Patient Care Partnership (formerly the Patients Bill of Rights)
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TYPES OF COMMITMENT TO A MENTAL HEALTH FACILITY
- Voluntary Commitment - read p/p page 4/15
- Involuntary Commitment - read p/p page 4/15; Clients still considered competent & have the right to refuse treatment
- Emergency Commitment - Prevent harm to self or to others
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SECLUSION & RESTRAINT -
Should be ordered for the shortest duration necessary & only if less restritive measures are insufficient.
Never be used for: staff convenience, client punishment, for clients who are physically or mentally unstable, & for clients who can't tolerate the decrease stimulation of a seclusion room
- Uses of Seclusion & Restraint
- Tx must be ordered by the PCP in writing & specify duration of Tx
- Client can be placed in seclusion or restraint in an emergency
- Order must be rewritten every 24 hours or as specified
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Check Circulation every 15 min, remove restraint evey 2 hours
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NURSE-CLIENT RELATIONSHIP - A therapeutic nurse - client relationship is:
Purposeful & goal directed; Well defined with Clear boundaries; Structured to meet the client needs
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FACTORS THAT HELP DEVELOP THE THERAPEUTIC RELATIONSHIP
- Nurse Factors: Self awareness of own thoughts/feelings
- Client Factors: Trustful attitude, Willingness to talk (rapport)
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THERAPEUTIC RELATIONSHIP
- Phases of the Therapeutic Nurse-Client Relationship
- Orientation, Working, Termination
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BOUNDARIES - must be established;
To reflect on boundary issues frequently, & to maintain an awareness of how behaviors are perceived
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TRANSFERENCE -
Example: The Client may see the nurse as being like his mother
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COUNTERTRANSFERENCE -
The nurse may feel defensive & angry with a client for no apparent reason
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THERAPEUTIC COMMUNICATION - The nurse must recognize & respond to both Verbal & Nonverbal Communications
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EFFECTIVE COMMUNICATIONS SKILLS & TECHNIQUES
- Silence - serves a function, such as time for meanigful reflections
- Clarification & Validation - of clients messages
- Open Ended Questions - to facilitate spontaneous responses
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INEFFECTIVE COMMUNICATION SKILLS & TECHNIQUES
- Taking the clients words at "face value", giving advice about the clients decisions.
- Giving approval or d-approval of clients thoughts, feelings or behavior which implies judgment or moralizing
- Close ended & "why" questions, which limit the clients responses
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ANXIETY - is a feeling of apprehension, or dread resulting from a real or perceived threat
- Levels of Anxiety
- Mild - occurs in the normal experience of everyday living, increase one's ability to perceive reality, has identifiable cause
- Moderate - occurs when mild anxiety excalates; slight decrease in perception; increased heart rate and respiratory rate
- Severe - Perceptual field is greatly reduced with distorted perceptions; not able to take direction from others.
- Panic-Level - not able to process what is occuring in the environment & may lose touch with reality
- Nursing Interventions for AnxietyProvide a calm presence, recognizing clients distressExplore Alternatives to problem situation
- Provide a quiet environment with minimal stimulation, stay with client if in panic state
- Encourage gross motor activities
- Set Limits by using firm short simple statements
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THERAPEUTIC MILIEU -Management of the Milieu means manipulating the total environment of the mental health
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Prevention of Client Sel-harm or Harm by Others - No access to sharp or otherwise harmful objects
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Client Care in Acute Mental Health Care Settings
Admissions Criteria - danger to self or other, failure of community based Tx, dangerous decomposition of a client undergoing long term Tx
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Interdisciplinary Team Members in Acute Care - The IDT has the Primary responsibility of planning & monitoring individualized Tx
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LEVELS OF PREVENTION
- Primary Prevention - promotes health & prevents mental health problems from occuring
- Secondary Prevention - Focuses on early detection of mental illness
- Tertiary Prevention - focuses on rehabilitation & prevention of further problems in clients previously diagnosed
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