ATI Mental Health CMS
Chapter 1; Basic Mental Health Nursing Concepts
→ Assessment
Mental Status Exam (MSE)
1) Level of consciousness:
- Alert
- Lethargic: client can open eyes and respond but is drowsy and falls a
...
ATI Mental Health CMS
Chapter 1; Basic Mental Health Nursing Concepts
→ Assessment
Mental Status Exam (MSE)
1) Level of consciousness:
- Alert
- Lethargic: client can open eyes and respond but is drowsy and falls asleep quickly
- Stuporous: client requires vigorous and painful stimuli to elicit brief
response
- Comatose: unconscious & does not respond to painful stimuli
Abnormal posturing in comatose client
Decorticate rigidity; flexion & internal rotation of upper extremity joints & legs
Decerebrate rigidity; neck & elbow extension, wrist & finger flexion
2) Physical appearance
3) Behavior
- Mood: emotion that she is feeling
- Affect: objective expression of mood, such as flat affect or lack of facial expression
4) Cognitive & intellectual abilities: orientation, memory, knowledge, calculation, illness perception, judgment, speech
- Immediate memory; repeat series of numbers or list
- Recent memory: visitors from current day, purpose of current appt
- Remote memory: fact from past, DOB, mothers name
→ Considerations Across The Lifespan
Children & Adolescents
- Assessment includes temperament social and environmental factors cultural and religious concerns and
developmental level. the client should be the source of the information but with children and adolescents
caregivers can also provide valuable information.
- Mentally healthy children and adolescents trust others view the world as safe accurately interpret their
environments master developmental tasks and use appropriate coping skills
HEADSSS standardized assessment tool
Home environment;
Education/employment;
Activities;
Drug/ substance abuse;
Sexuality;
Suicide/depression;
Safety
→Mental Health Diagnoses
• The Diagnostic & Statistical Manual of Mental Disorders 5th Edition (DSM-5)
- Used by mental health professionals
- establishes diagnostic criteria for mental health disorders
- identifies expected findings for mental health disorders
- used by nurses to plan implement and evaluate care for clients who have mental health disorders
• Serious Mental Illness
- Includes disorders classified as severe and persistent mental illnesses
- Clients often have difficulty with activities of daily living
- Are lifelong disorders that can have remissions and exacerbations
→ Therapeutic Strategies in The Mental health Setting
• Counseling; using therapeutic communication skills, assisting with problem solving, crisis intervention,
and 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, and assisting the client to participate in appropriate
activities
• Promotion of self-care activities; helping with self-care task, allowing time for the client to complete
self-care task, and setting incentives to promote client self-care
• Psychobiological interventions; administering prescribed medications, providing teaching to the client
and family about medications, and monitoring for adverse effects and effectiveness of pharmacological
therapies
• Cognitive & behavioral therapies; modeling, operant conditioning, systemic disinvitation
• Health teaching; teaching social & coping skills
• Health promotion & maintenance
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