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The school teacher who led a crusade for humane treatment and 32 state hospitals providing food, clothing, and shelter.
Dorothea Dix
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School teacher, who recognized the value of Englands system of "asylum: for mentally ill persons.
Credited with setting up a similar system in the US and 32 "state" hospitals were opened.
Dorthea Dix
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The "Florence Nightingale" of mental health.
Believed that mentally ill persons were entitled to the same standard of care that the physically ill received.
Improved nursing care and started educational programs.
Linda Richards
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Early roles of mental health nursing:
Nutrition, hygeine, and activities while practicing tolerance and kindness.
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Later roles of mental health nursing:
Insulin shock and psychosurgery
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Current roles of mental health nurses:
- Counseling
- Milieu therapy
- Self-care focus
- Pharmacologic issues
- Case management
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Scientific planning related to social and physical environment with with a goal.
Milieu Therapy
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Nursing roles in milieu therapy are....
- maintains therapeutic environment
- teaches skills
- promotes communication
- uses role-modeling.
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Under a voluntary admission the mentally ill client agrees to treatment.
Client retains all of their civil liberties.
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Under voluntary admission the client may discontinue treatment whenever they choose.
True.
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Under voluntary admission, if the treatment team disagrees with their decision to stop treatment, it is considered leaving AMA.
True.
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Under involuntary inpatient commitment the client is institutionalized against their will.
These clients have posed a threat to themselves or others.
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Involuntary commitment:
State guidelines specify time limits and conditions for evaluation and care.
If the client is committed for extended car e- ongoing legal hearings are specified.
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What rights do clients under protective custody retain?
All civil rights except the right to LEAVE the HOSPITAL.
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Rights of mentally ill:
May send or receive mail, have or refuse visitors, telephone priviledges.
May refuse medications, UNLESS court ordered!
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Restrictions that may be used of mentally ill:
(these are physician ordered/court mandated)
- Suicide precautions
- certain visitors may be restricted
- May require supervised telephone calls
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May only use seclusion and restraint when:
To prevent the client from hurting themselves or others.
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Involuntary outpatient care - court mandated treatment
More difficult to enforce since these persons are out in the community.
Often implemented in cases of substance impaired persons, the homeless mentally ill, or sex offenders.
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Involuntary commitment does not mean that the person is incompetent
They retain their civil liberties under these commitment conditions.
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Example of court mandated treatment:
Clients with a hx of spousal abuse, in Lubbock, may receive mandatory training as part of the conditions of their sentence.
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Least restrictive environment is used when:
The client is competent enough to comply with outpatient therapy, it over=rides hospitalization
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Moving care to the community setting is called
Deinstitutionalization
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Deinstitutionalization is a good idea but problems in application due to:
- inadequate funding
- planning failed to consider non medical issues
- revolving door effect in many instances (the go in come out go in and come out)
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Issues affecting care:
- Unexpected or non medical issues
- Housing
- Transportation
- Money management
- Food preparation
- Safety
- Hygiene
- Accessibility to resources
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Prevent problem from ever occuring.
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Early diagnosis and treatment
Secondary prevention
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Continued support and rehabilitation
Tertiary
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Using seatbelts
Suicide prevention
Which prevention?
Primary prevention
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Child with measles
Teachers look for "at risk" kids
Which prevention?
Secondary Prevention.
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Child with measles gets sicker
Getting immediate care and needs hospitalization
Which prevention?
Tertiary Prevention
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Universal criteria when determining the severity of mental illness?
Is this client posing a risk or danger to themselves or others?
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Decompensation:
Not coping, loosing touch with reality.
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Confidentiality is considered a part of the nurse client relationship and concerns respecting personal info and limiting access.
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Duty to Warn is the result of a court ruling from 1976 that determined protective privilege ends when public peril begins.
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Duty to warn criteria:
- Is the client dangerous to others?
- Is the danger the result of a serious mental illness?
- Is the danger imminent?
- Is the danger targeted at identifiable victims?
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Nursing actions with duty to warn:
(the typical rules for confidentiality and medical records to not apply here)
Once the info is obtained the following should be notified:
- Intended victim
- Law enforcement
- Nursing supervisor
- Attending physician
- According to text - practical or clinical applications may vary
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Can the hospitalized mentally ill client refuse treatment?
- They do have this "right".
- In special cases, they may receive emergency medications, court ordered medications, or be under seclusion or restraining measures.
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Most lawsuits in the mental health setting are due to suicide or suicide attempts.
Additional areas may include the client harming others, instances of sexual assault and medication errors.
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An act that results in a person's genuine eat of being touched or otherwise violated without their consent.
Assault
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Ranges from touching without consent to causing harm or injury.
Battery
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The nurse could or couldn't be charged with "false imprisonment" if they use seclusion, limit a person's access to their clothes in a non emergency situation
COULD, they can be charged with false imprisonment.
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Culturally competent nursing care means:
being sensitive to issues related to culture, race, gender, sexual orientation, social class, and other variables.
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The belief that one's own culture is superior to others and the standard or norm by which all other cultures are measured
Ethnocentric
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When a nurse is ethnocentric the client may feel:
- out of sync
- misunderstood
- alienated
- in conflict with their provider
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When a nurse is ethnocentric the client may also feel:
The client may feel deprived of the benefit of a therapeutic relationship labeled as non compliant and may not understand their treatment plan.
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The belief that all cultures are equally valid and equally deserving of respect:
Ethnorelative
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When a nurse is ethnorelative they are:
- Empathetic
- caring and open
- flexible
- positive attitude
- holistic
- nonjudgmental
- able to communicate effectively
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The first step of the nursing process where specified date is gathered, organized and documented.
Assessment
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Tool used to enhance the effectiveness of the interview.
Verbal and nonverbal therapeutic communication techniques.
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Are closed-ended questions acceptable when conducting a nursing assessment?
- Yes.
- This question is helpful when specific info is required or when the client is unable to organize their thoughts.
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Subjective Data:
- Past mental illnesses
- Family/Medical hx
- Allergies
- Rx's
- Substance abuse
- Education
- Safety
- Cultural concerns
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Objective Data:
- Physical assessment and findings
- Lab values
- Mental Status:
- Appearance
- Behavior
- Affect and mood
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Repeated purposeless behaviors relaying anxiety such as drumming fingers, twirling hair or tapping foot.
Automatisms
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Overall movements are slowed
Psychomotor retardation
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Maintenance of posture or position over time despite awkwardness or discomfort
Waxy flexibility
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The outward expression of the client's emotional state.
Affect
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Affect showing little or slow to respond facial expressions
Blunted
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Affect displaying a full range of emotional expressions.
Broad
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Affect showing no facial expression
Flat
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Affect that does not apply to the situation or mood
Inappropriate
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Affect showing only one type of expression usually serious or somber.
Restricted
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Type of mood:
When the client exhibits unpredictable and rapid mood swings ex: euphoria to depressed
Labile mood
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Terms to describe moods:
- Happy
- Sad
- Depressed
- Euphoric
- Anxious
- Angry
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Refers to how the client thinks.
Thought process
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When the client eventually answers the question after giving large amounts of unrelated information first.
Circumstantial thinking
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Fixed false belief that is not based on reality.
Delusional
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Excessive amount and rate of speech which consist of fragmented or unrelated ideas.
Flight of ideas
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When the client believes that general events are directed to him such as believing the television announcer is speaking directly towards them.
Ideas of reference
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Disorganized thinking that jumps from one idea to another and unrelated in content
Loose associations
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Wandering off the topic and never answering the questions
Tangential thinking
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Stopping abruptly in the middle of a thought or sentence and unable to resume the idea.
Thought blocking
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A delusional belief that others can hear or know their thoughts.
Thought broadcasting
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Others are putting ideas or thoughts into their head
Thought insertion
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Others are removing their thoughts
Through withdrawal
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Flow of unconnected words that convey no meaning to the listener.
Word salad
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Questions used to assess memory:
- What is the name of the current president?
- Who was the president before that?
- In what country or county do you live?
- What is the capital of this state?
- What is your social security?
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Questions used to check client's ability to concentrate:
- Spell the word world backward
- Begin with 100 and subtract 7 then subtract 7, so on.
- Repeat the days of the week backwards
- Perform a 3 part task
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Type of thinking: The ability to make associations or interpretations about a situation or comment.
abstract thinking
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Sensory perceptual alterations.
Is the client hallucinating?
- Auditory - hearing voices
- Visual - seeing things
- Tactile - touch - electricity running through body
- Olfactory - smells or odors
- Gustatory - taste that lingers in mouth
- Cenesthetic - undetectable body sensations
- Kinesthetic - sensation of body movements
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Ability to understand the true nature of one's situation or problem and accept some personal responsibility.
Insight
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Perception:
Awareness of reality versus fantasy.
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Suicide ideation question:
- Ideation: Are you thinking of killing yourself?
- Plan: Do you have a plan to kill yourself?
- Method: How do you plan to kill yourself?
- Access: How would you carry out this plan? Do you have access to a gun?
- Where: What is the location where you would kill yourself?
- When: When do you plan to kill yourself?
- Timing: What time of day would you carry out your plan?
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Duty to Warn:
If the client is angry or hostile or "threatening" when referring to friends, family, or others this should be explored!
What thoughts have you had, what is your plan, what do you intend to do?
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Nursing diagnosis or Medical diagnosis?
A statement about the client's response to a health disruption.
Nursing diagnosis
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Nursing diagnosis or Medical diagnosis?
A method to describe the condition and its effect on the family or individual
Nursing diagnosis
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Nursing diagnosis or Medical diagnosis?
Serves to direct nursing management.
Nursing diagnosis
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Nursing diagnosis or Medical diagnosis?
Based on the Diagnostic and Statistical Manual of Mental Illness (DSM-IV)
Medical diagnosis
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Nursing diagnosis or Medical diagnosis?
Provides diagnostic criteria for each mental disorder.
Medical diagnosis
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Nursing diagnosis or Medical diagnosis?
Uses 5 axes to give a comprehensive overview
Medical diagnosis
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DSM-IV multi-axial system
What Axis (I-V)
Clinical disorder that is the focus of treatment such as major depression, autism
Axis I
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DSM-IV multi-axial system
What Axis (I-V)
Personality disorders, mental retardation
Axis II
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DSM-IV multi-axial system
What Axis (I - V)
General medical conditions such as asthma
Axis III
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DSM-IV multi-axial system
What Axis (I - V)
Psychosocial and environmental problems such as educational deficits, housing problems, financial difficulties, etc.
Axis IV
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DSM-IV multi-axial system
What Axis (I - V)
Global Assessment of Functioning (GAF)
Axis V
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Assigns a numerical value representing the client's current level of
functioning compared to the highest level of functioning during the past
year.
GAF
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Expressed as a fraction such as 45/70
GAF
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A high GAF indicates what?
High level of functioning
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Scores between 50-60 on the GAF indicate:
moderate severity of symptoms
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Clients with suicidal ideations are given a score of what on the GAF?
50
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Clients with a score of 10 on the GAF could have symptoms of what?
violence, severe ability for self harm, or evidence of minimal personal hygiene.
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Nursing diagnosis in mental health:
3 part format: Diagnostic label, etiology and causative factors (related to) and defining characteristics (as evidence by)
Risk for self directed violence related to feeling of hopelessness, helplessness,and unresolved grief tendencies as evidenced by patient stating "I can't live like this anymore"
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