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NUR2225 > Wk 2: Metal health assessment > Flashcards

Wk 2: Metal health assessment Flashcards

1
Q

Describe a comprehensive assessment

A
  • a key skill in mental health nursing
  • dynamic and dependent on the person
  • dependant on the therapeutic relationship and how well the practitioner can relate
  • can be formal (assessment on admission) or informal (in the community watching TV)
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2
Q

what is the purpose of a comprehensive assessment?

A
  • Communicate, identify and clarify the person’s mental health issues
  • Assess the person’s physical health status (exclude organic causes)
  • Identify personal/family/social supports that can be utilised in collaborative care and treatment planning
  • Provides the person/carers/family the opportunity to express concerns throughout the assessment process
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3
Q

What are the 16 components of a comprehensive assessment?

A
  1. Reason for referral
  2. Consumer’s response to the referral
  3. Presenting problem/s
  4. History of presenting
  5. Mental health history
  6. Family history of mental health problems
  7. Substance use history
  8. Physical health/medical history
  9. Social and developmental history
  10. Trauma
  11. Cultural/spiritual needs
  12. Forensic history
  13. Mental state examination (MSE)
  14. Risk assessment
  15. Clinical formulation and summary
  16. Plan
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4
Q

What is included in the ‘Reason for referral/presentation’ section of an MSE?

A
  • To understand where the person has come from, or what has brought them here.
  • ensure to find this out from the person
  • There may or may not be a referral letter
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5
Q

What is included in the ‘consumer’s response to the referral’ section of an MSE?

A
  • The person’s perspective is important
  • why they think they are here
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6
Q

What is included in the ‘presenting problem’ section of an MSE?

A
  • To understand what is going on for the person at the time.
  • Also helps clarify the person’s expectations
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7
Q

What is included in the ‘History of presenting problem/s’ section of an MSE?

A
  • To establish the duration of the problem
  • fluctuations in severity etc.
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8
Q

What is included in the ‘Mental health history’ section of an MSE?

A
  • Any previous mental health problems should be noted, as the current situation may be a pattern, exacerbation, or a break in the person’s coping.
  • Also include any past medications/treatment for the past problem, whether it was useful etc.
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9
Q

What is included in the ‘family history of mental health problems’ section of an MSE?

A
  • Some mental health problems are commonly experienced by family members; a history of family mental illness can be a predisposing factor.
    *Also include suicide/self-harm.
  • some presentations/disorders have genetic links
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10
Q

What is included in the ‘substance use history’ section of an MSE?

A
  • Some mental health problems are exacerbated by substance use, or substances are used as a coping mechanism.
  • Type of substances
  • route of use
  • circumstance of use should be noted. E.g. At home by self when stress or recreationally with friends on weekend
  • any attempts to cease use.
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11
Q

What is included in the ‘Physical health/medical history ‘ section of an MSE?

A

Physical health is often overlooked. People with mental health problems have high rates of co-occurring physical health problems.
- Some physical health problems may contribute to mental health problems.

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12
Q

What is included in the ‘social and developmental history’ section of and MSE?

A
  • A persons development influences the shaping of personality, and how the person responds to stress.
  • It’s important to understand family dynamics and supports the person has.
  • Areas of sexuality, schooling, and employment should be included here.
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13
Q

What is included in the ‘Tramua’ section of and MSE?

A
  • trauma is a contributing factor to mental ill
    health
  • may limit the person’s willingness to engage with mental health services.
  • It’s important to consider all areas of potential trauma.
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14
Q

What is included in the ‘Cultural/spiritual needs’ section of and MSE?

A
  • Culture can influence how a person experiences and responds to mental ill health.
  • Care also needs to be culturally sensitive and
    respectful.
  • Culture can be a barrier for engagement, or may act as support for the person.
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15
Q

What is included in the ‘Forensic history’ section of and MSE?

A
  • It is not uncommon for people with mental illness to have had contact with the justice system.
  • increased engagement in forensic behaviour
  • ?jail
  • ?arrest
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16
Q

What is the purpose of the ‘Mental state examination’ section of and comprehensive assessment?

A
  • Provides a ‘snap shot’ of the person’s current presentation and mental state at a single point in time
  • allows for comparison in the future.
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17
Q

What is included in the ‘risk assessment’ section of and MSE?

A
  • Safety is central to the provision of quality mental health services.
  • A risk assessment encompasses everything in the person’s background and current risks
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18
Q

What is included in the ‘clinical formation and summary’ section of and MSE?

A

This is a summary of the significant information from the assessment and attempts to show a relationship between different areas and how these may influence a person’s mental health.
- can be provided to the person as a form of appreciative listening.

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19
Q

What is included in the ‘plan’ section of an MSE?

A
  • must have one
  • no point in an assessment without a plan
  • include the nurse’s and the person’s strategies and actions moving forward.
  • Collaborative care is paramount in mental
    health nursing and supportive of the person’s recovery.
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20
Q

What is the purpose and benefits of an MSE?

A
  • Provides a ‘snap shot’ of the person’s current presentation and mental state at a single point in time, which allows for comparison in the future
  • It does not reflect; how the person was in the past or will be in the future. NOTE THIS- MSE IS VERY CONCURRENT
  • some areas of MSE are not asked by observed
  • conducted conversationally or more formal
  • Enables clinicians to identify areas of need/concern and plan appropriate interventions
  • MSE should be performed frequently and in any changed life situation e.g. transfer of care, loved one died
  • A person’s presentation can fluctuate from day to day, morning to afternoon, and is
    dependent on what else is going on for the person (eg. transfer between services or
    receiving bad news)
    • thus multiple can be performed in a day
  • Can be conducted in a variety of settings. Consider
    - privacy
    - distractions
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21
Q

What factors determine the accuracy of an MSE?

A

Depends on the nurses;
- attitude
- experience
- observational and listening skills

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22
Q

What are key points to note when starting an MSE or comprehensive assessment?

A
  • The person needs to be informed of your identity, designation and purpose of the interview

Always be;
- tactful
- culturally respectful
- show acceptance
- gives simple introductory explanations

The nurse should;
- ask open questions
- allow for pauses
-so the person can respond.
- DO NOT lead or provide answers for the client

  • When incongruence exists, the nurse can discreetly observe the person to validate their
    subjective vs. objective presentation
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23
Q

What are the components of an MSE?

A

PAMSGOTJIMI- note this is not how you would document the assessment- needs to be done in the order on the left.
Perception
Affect and mood
Motor activity
Speech
General appearance
Orientation,
Thought (content/process)
Judgement,
Intellectual functioning
Memory
Insight

Correct order: Green bean stalks move promiscuously though the internal juodenum more often intelligently.
- General Appearance
- Behaviour /Motor Activity
- Speech
- Mood and Affect
- Perception
- Thought Content
- Thought Form/Process
- Insight
- Judgement
- Memory
- Orientation
- Intelligence/intellectual functioning/cognition

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24
Q

What should be assessed in the ‘appearance’ section of an MSE?

A
  • Overall general appearance.
  • Consider if the person is dressed appropriately for the climate/weather,
  • attention to hygiene and grooming
  • presentation may show symptoms of their diagnosis e.g. depression=neglect of person hygiene or manic=flabouiant dressing

Includes the person’s physical characteristics
- Height
- Weight
- Hair style/colour
- Whether they look older/stated age/younger
- Body markings (scars, tattoos, birthmarks)
- Jewellery (piercings)
- make-up/lack of/or grooming

  • if a person goes AWOL we need to know their appearance to describe to the police.
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25
Q

What should be assessed in the ‘behaviour’ section of an MSE?

A

Assess the quality and quantity of movement;
- posture
- gait
- hyperactivity
- restlessness
- agitation
- wringing hand
- psychomotor retardation
- Observe non-verbal communication, such a body language and posture (relaxed, ridged, tense)
- Eye contact and facial expressions (avoidant, staring/fixed, intense) – be mindful of culture
- Motor activity (slowed, immobile, restless, pacing, wringing hands)
- Verbal communication: attitude to interview (e.g. easily engage, hostile), familiarity (e.g. overfamiliar, inappropriate, disinhibited)

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26
Q

What should be assessed in the ‘speech’ section of an MSE?

A
  • quality
  • quantity
    - ?are they trying to get heaps out
  • volume
  • tone

Useful words for documentation
- talkative
- expansive
- poverty
- fast
- slow
- norm
- pressured
-loud
- monotone
- slured
- clear

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27
Q

What should be assessed in the ‘mood and affect’ section of an MSE?

A

Affect: is the objective observation of the person’s emotional expression
Includes observing;
- fluctuations: labile or even;
- range: broad or restricted;
-intensity: blunted, flat, normal;
- quality: anxious, angry, animated, euphoric, hostile

Mood: is the person’s account of their emotional state (subjective), is sustained and pervasive, and influences the person’s interpretation of the world

Mood may be described as;
- happy
- sad
- depressed
- angry.
- Person can rate their mood on a scale from 1-10:

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28
Q

What should be assessed in the ‘perceptions’ section of an MSE?

A

= Assess the presence of altered perceptions eg. hallucinations, illusions, derealisation or depersonalisation.
- a person can experience perspective disturbances in any of their five senses.

May include;
- hallucinations
- illusions
- De-personalisation
- De-realisations

29
Q

What are the types of hallucinations?

A

Auditory: perception of sound (e.g. noises, music, voices) without outside stimulus
- person might say they hear music but there is none

Visual: perception of a visual stimulus (e.g. people, shapes, objects) where none exists
- a person might say they see a cat but there is a stimulus in something

Olfactory: smelling an odour (typically foul smelling) without outside stimulus
- may say they smell blood or feces

Gustatory: perception of taste without a stimulus

Tactile: illusion of tactile sensory input without outside stimulus (e.g. sensations of bug crawling on the skin)

30
Q

Define an illusion

A

= misinterpretation of external stimuli

31
Q

Define de-personalisation

A

= person feels as if they don’t exist

32
Q

Define de-realisation

A

= person feels as though the would around them doesn’t exist

33
Q

What should be assessed in the ‘thought content’ section of an MSE?

A

= Assesses what the person is thinking and can include;
- obsessions
- delusions (persecutory, grandiose, bizarre)
- phobias
- magical thinking
- thoughts of harm to self/others
- Hope for the future
- thought broadcasting
- thought insertion
- ideas of reference
- magical thinking

34
Q

Define a delusion

A

= a fixed false belief that is firmly held by a person, despite proof or evidence to
the contrary (also not in line cultural beliefs).

35
Q

What are the 6 types of delusions and what do they mean?

A

Persecutory/paranoid: that someone or something intends to harm the person or others

Grandiose: that the person has special abilities, power or authority

Somatic: are false beliefs involving the functioning of one’s body for example the belief that one’s brain is rotting or melting. e.g. the they are pregnant

Erotomanic: that another person is in love with the person or wants to commence a relationship

Infidelity: the person is convinced their partner is being unfaithful

Control: where another person or force is interfering with the persons thoughts / actions
(passivity phenomena) against their will

36
Q

Define thought broadcasting

A

Is the delusion belief that one’s thoughts can be heard by others, as though they are being broadcast into the air

37
Q

Define thought insertion

A

Is the delusion that thoughts are being implanted in one’s mind by other
people or forces

38
Q

Define ideas of reference

A

Are false beliefs that insignificant remarks, or events refer back to one or have special meaning

39
Q

Define magical thinking

A

Resembles a young child’s thinking whereby thoughts, words or actions assume power, that is, they can cause or prevent events

40
Q

What should be assessed in the ‘thought process/form’ section of an MSE? and what are different alterations to form?

A
  • Assesses the way in which the person puts together ideas
  • Articulated through expression of ideas and through speech
  • Consider whether the person’s thoughts makes sense.
  • Whether they are logical or disordered (circumstantial, tangential, derailment, looseness of associations, word salad)

Alterations to though form include:
- Circumstantiality: excessive detail and not getting to the point
- Derailment: no logical connection between ideas, sentences not making sense due to word
choice
- Flight of ideas: thoughts moving quickly from one to another
- Neologisms: made up/invented words
- Perseveration: repetition of words/phases out of context
- Thought blocking: breaks/pauses/stops in the flow of ideas
- Tangentiality: loose answers to a question

41
Q

What should be assessed in the ‘intelligence/cognition’ section of an MSE?

A
  • General intelligence
  • Consider whether the person is alert and oriented to the time time/place/person
  • Where alteration to a person’s cognition is present, the Mini Mental State Examination is
    used
42
Q

What should be assessed in the ‘insight’ section of an MSE?

A
  • Refers to the person’s own perception of their current difficulties, the cause, and what can
    be done to alleviate/improve the situation
  • Assess the person’s understanding of their current situation, mental health problem/treatments
  • Can be have partial, poor, limited or good insight. Can differ depending on the situation
43
Q

What should be assessed in the ‘judgement’ section of an MSE?

A
  • Judgement is the person’s capacity to make sound and reasoned decisions
  • Consider whether the person can establish the consequences of their actions – do they
    have good judgement?
  • Consider problem solving ability in their current context
    e.g. if they had a stamped envelop next to a post box what would they do?
    e.g. walking on a free way in the middle of the night? not safe so if someone is doing this we know their judgement is off
44
Q

What should be assessed in the ‘age’ section of an MSE?

A
  • Lack of rapport/therapeutic relationship
  • Physical environment (e.g. lack of space/privacy)
  • Age
  • Health literacy
  • Cultural and language barriers (cultural relation to symptoms and if they exist where they grow up, if mental health in an issue in their culture)
  • Stigma
  • Cognitive state or intellectual impairment (e.g. memory deficits, confusion)
  • Mood altering substances (e.g. amphetamines)
45
Q

Why is a quality risk assessment circial in MHN?

A
  • risk is a major reason a person may come into contact with mental health service.
  • note that placing smoneunder an order a point of assessment is ‘risk’
  • Acuity of the risk may influence but not necessarily determine follow up by mental health services

When assessing risk, the nurse/midwife needs to consider:
- acuity of the risk
- The likelihood of the risk occurring
- Is the risk imminent or delayed?
- Should an event happen, what’s the severity?
- Accuracy of the risk assessment is enhanced by collateral information from family, friends
or other relevant persons

46
Q

What are some different forms of risks?

A

Risks can include:
- violence
- aggression
- self-harm
- suicide
- self-neglect
- relapse

Risks can be:
- short
- medium
- long term

Risk factors can change over time and may change as the person’s circumstances change
e.g. become drug effected and thus become at risk for self harm.

47
Q

What are the three main approaches to understanding risk?

A

Unstructured clinical judgement: based on clinician’s experiences or ‘gut feelings’

Actuarial approaches: use of risk assessment tools (e.g. Historical-Clinical-Risk-20 [HCR-20])

Structured clinical judgement: combines both of the above – considered to be the preferred
- most reliable
- combines both of above rools

48
Q

What are the three factors that influence risk? and what do these mean?

A

Static risk factors:
- are historical factors and are not subject to change.
e.g. gender, personal history, medical and mental health history (including onset of mental health problems and past diagnosis/treatment), offending history, and family history

Dynamic risk factors: are those that are subject to change.
e.g. age, substance use, clinical acuity/stability, and psychosocial stressors

Protective factors;
- may reduce the impact of a problem, or reduce the negative impact of a risk
factor on a problem or outcome.
e.g. personal strengths, skills and
resources, identified by the consumer or with the multidisciplinary team, family members/carers (Higgins et al., 2015)
- In supporting recovery-oriented mental health practice, risk assessment must take into consideration the consumer’s strengths and any protective factors

49
Q

What are some early warning signs of risk?

A

= signs and symptoms that someone may present with that may lead to complications/risks.
e.g. someone not sleeping may lead to relapse

  • what signs or behaviours might present, prior to an elevation in a person’s risk (or precipitating violence and/or aggression)

Early warning signs differ from person to person, but may include;
- sleep disturbance
- anxiety
- feelings of being targeted or picked on
- withdrawal
- drug use
- pacing (can be at risk of violence or aggression)
= anything that indicates signs of deterioration

  • It is important to discuss early warning signs with the person and ensure that this
    information is available to those involved in the person’s care. Write this into their care plan.
50
Q

What are the 4 different classifications of risk and what is included in them?

A

Risk to self

Risk to others

Risk by/from others

Iatrogenic risks (risks associated with
engaging with the MH system)
-

51
Q

What may be consider ‘risk to self”?

A

Risk to self
- Self-harm, non-suicidal self-injury
- Suicide
- Self neglect
- Reputation
substance misuse
- Medication non-adherence
- Physical health issues
- Legal issues related to offending
- Deliberate or unintentional harm to self (selfharm, suicide)
- Loss of social/financial status resulting from
mental health problems (e.g. employment/accommodation loss, loss of
family/friends other support
- Risks to physical, mental and sexual health as a result of engaging in ‘risky behaviours’

52
Q

What may be considered risk to others?

A
  • Interpersonal violence
  • Sexual assault/abuse
  • Harassment
  • Property damage
  • Stalking behaviour
  • Violence
  • aggression
  • Neglect or abuse of children or adults where
    care is provided
  • Reckless or high-risk behaviours (e.g. drink
    driving)
53
Q

What may be considered at risk by/from others?

A
  • Assault
  • Sexual exploitation/abuse
  • Financial exploitation/abuse
  • Verbal abuse
  • Physical, sexual, emotional abuse by others
  • Victimisation/harassment
  • Being unfairly treated
  • Loss of accommodation or difficulty obtaining
    accommodation
54
Q

What may be considered latrogenic risks?

A

=(risks associated with engaging with the MH system)
- Diagnosis/labelling
- Erosion of identity/self-esteem, loss of autonomy institutionalisation
- Stigma
- Trauma (seclusion/restraint)
- Negative/controlling attitudes and behaviours of staff
- Violation of human rights
- Health problems associated with medication side effects e.g. antipsychotics=weight gain=T2DM

55
Q

Again, what ate the main considerations when assessing risk?

A
  • what is the likelihood of this risk occurring?
  • is the risk imminent or delayed
  • if it happened, what is the severity?
56
Q

What are some verbal vs non-verbal ques that someone is at risk of suicide?

A

verbal: “ive had enough”, “this place would be better off without me”
non-verbal loss of interest in activity they usually, giving away/getting rid of belongings

57
Q

What are some important questions to ask directly to someone who has thoughts of self-harm/suicine?

A
  • do u have a plan? time? date?
  • what is the method?
  • lethality of the methods?

Ask about protective factors

58
Q

What are guiding principles in assessing suicide risk?

A

Positive engagement
- Good communication and listening are vital to establish rapport
- Validate the person’s feelings
- Ask the person directly: are you thinking about suicide?

Gathering information
- From the person: ascertain the person’s level of distress, thoughts and feelings about their life. Have they made any preparations
for death (e.g. giving away valuable items, saying goodbye to loved ones)
- From others: gather information from people around them if possible – this can help gauge level of risk and determine appropriate
interventions/options

Thorough assessment
- What is the level of the person’s distress? What are the sources of their distress?
- History of suicidal behaviour (Has the person felt like this before? Have they harmed themselves before? What were the details of
the previous attempt? Is their a family history of suicide?
- Current thoughts, plan, lethality/intent, access to means?
- Protective factors, coping skills

Follow-up assessment
- Initial assessment should always have a follow up assessment (comprehensive mental health assessment, MSE)

59
Q

What are key points for the training team when dealing with someone at risk of self harm or suicide?

A
  • Take any threat seriously (and evaluate before dismissing it)
  • Talk about suicide openly and directly
  • Implement suicide precautions (ie. Reduce access to ‘sharps’, the person needs to not be in a space which is closed off, frequent or ‘special’ observations, searches of the person’s belongings for access to potentially harmful objects and remove where risk is high)
  • Remove the person from immediate danger
    • but consider how de-humanising/humiliating this may be for someone
  • Be aware of where the person is (locate the person near the nurses station)
  • Do not make unrealistic promises (ie. Don’t worry, everything will be okay- these are not helpful)
  • Encourage the person to be involved in managing their safety and development of the plan
  • Encourage the person to be involved in activities, ADL’s
  • Where possible involve family, and be mindful that families/carers may be worried, confused or angry
  • Identify what the person’s needs are
  • Assume a non-judgemental, caring attitude that does not engender self-pity in the person
  • Work effectively with the multidisciplinary team
60
Q

What are some considerations around recovery-orientated language when dealing with someone at risk of self-harm/suicide?

A

The words we use reflect our value, belief and respect for people. Our language needs to
be respectful and non-judgemental. We need to ensure that the language we use when
discussing self-harm and suicide demonstrates this respect, acceptance, hope and
uniqueness of the person

  • The person (name) is experiencing thoughts of self-harm/suicide
  • The person (name) tends to self-harm when upset
  • Died by suicide (rather than ‘committed’)
  • Suicided (rather than ‘successful suicide’)
  • Ended his/her life, took his/her own life
  • Non-fatal attempt at suicide (rather than ‘failed suicide’)
  • Attempted to end his/her life (rather than ‘unsuccessful suicide’)
61
Q

What are some considerations around violence and agression when dealing with someone at risk of self-harm/suicide? and hat are some risk factors for violence and aggression?

A

All individuals have the potential to become violent and/or aggressive, should contributing
factors be sufficient in decreasing the person’s ability to tolerate frustration, pain or
confusion.

Risk factors
Past history: previous violence/threats, forensic/offending history, male aged 35 years and below, drug and/or alcohol abuse/use, poor engagement
Current issues: expressing intent to harm others/property, access to weapons, intoxication
Mental state: e.g. anger, rage, subjective feelings of danger, anxiety, agitation, sudden affect changes, command hallucinations and/paranoia
Environmental factors can also affect aggression: overcrowding, peak times when staff are not available (e.g. handover), staff rigidness, staff profiles (new grads), staff inability to recognise escalating behaviour or identify cues, restraint, care provision

62
Q

What are some key points of risk management when dealing with violence and aggression?

A
  • The person needs to know who you are and what your role is
  • Keep a safe distance from the aggressive person, don’t approach the person unexpectedly
  • Do not place yourself in the corner of a room or where an exit is not freely accessible
  • Be clear about unacceptable behaviour
  • Inform other staff
  • Be mindful of object in the area (e.g. chairs)
  • Personal duress alarms when neededThe person needs to know who you are and what your role is
  • Keep a safe distance from the aggressive person, don’t approach the person unexpectedly
  • Do not place yourself in the corner of a room or where an exit is not freely accessible
  • Be clear about unacceptable behaviour
  • Inform other staff
  • Be mindful of object in the area (e.g. chairs)
  • Personal duress alarms when needed
63
Q

Define de-escalation

A

= is the use of assertive communication skills to therapeutically connect with the person

64
Q

What is the most effective tool for de-escalation? and explain this.

A

= it is you, is the use of assertive communication skills to therapeutically connect with the person.

Verbal:
Voice: calm, but loud enough for the person to hear; speak slowly and clearly

Identify expectations: identify the person’s expectations may lead to understanding what is troubling them

Identify need: what need is not being met? This may cause hopelessness or feelings of disempowerment

Use plain and direct language: short and simple words will help the person understand when they may not be able to absorb information due to arousal

Actively listen and paraphrase: “I understand you are angry because of…” This allow clarity of understanding

Set limits: assertively set limits on behaviour and explain the reason (e.g. “you cannot smoke in the unit because smoking is banned inside the hospital, but we may be able to arrange for you to go outside”

Non-verbal:
Maintain a calm presence and pay attention: your behaviour may calm the person’s behaviour, take slow deep breaths

Maintain and open and relaxed posture: this is non-threatening (e.g. open body language, arms
by side)

Maintain appropriate eye contact: avoid staring/intent eye contact, remember cultural
appropriateness

Be aware of your non-verbal behaviour: do not copy the person’s behaviour/posture or language as this escalates the situation

Where possible, increase personal space: avoid touching them or being too close

65
Q

What are some ways to de-esclate and reduce violence and aggression? and why is it important?

A

= De-escalation often diffuses aggression and reduces the likelihood of violence
- ‘Safe spaces’, sensory rooms also assist with de-escalation
- ‘Safe Wards’

When a person remains an imminent risk to themselves or others, and where other less
restrictive interventions have not been effective, seclusion or restraint can be used (refer to
Mental Health Act lecture)
1. Seclusion: ‘the sole confinement of a person to a room or any other enclosed space where it is not within the control of the person confined to leave’ (pg. 12)

  1. Bodily restraint: ‘means a form of physical or mechanical restraint that prevents a person from having free movement of his or her limbs, but does not include the use of furniture…’ (pg. 2)
66
Q

Define and describe a safeward

A

Is an evidence based model to reduce conflict and containment within mental health services in which the causes of behaviours in staff and patients that may potentially result in aggression and violence is identified and addressed to reduce the chances of this occurring.

There are ten main interventions and are very helpful strategies to reduce conflicts and containments.
These include;
‘Know each other’,
‘Clear mutual expectations’,
‘Positive words’,
‘Discharge messages’,
‘Mutual help meeting’,
‘Reassurance’,
‘Bad news mitigation’,
‘Soft words’,
‘Calm down methods’,
and Talk down methods’.

To explore this model visit the Victorian Department Safewards training resource’s webpage.

67
Q

Define and describe sensory modulation rooms

A

= are also used to divert escalating clients.

This is where the mental health nurse will engage the client on an individual basis and utilize their therapeutic communication skills to respond to the client’s immediate needs, before deescalating the client while using the equipment in the room to calm and distract the client.

68
Q

What are some key principles when providing chemical restrains to someone who is at/a risk?

A

When administering PRN medications as ordered on the client’s medication chart, it is vital to use the least restrictive methods of administration where possible (per the Mental Health Act, 2014 (Victoria)).

Begin with tablets and syrup then move to intramuscular injection, if required. In the event PRN medications are not documented, the mental health nurse will need to obtain a phone order for the client for administration.

To minimize the incidences of Neuroleptic Malignant Syndrome (NMS), and other side effects, it is best practice to minimize the type and range of medications administered to the client.

Monitoring and documenting the medications’ effect, the client’s vital signs and co-morbidities also needs to be undertaken. Close attention to monitoring and documentation of vital signs is essential post administration, especially when the client has not had the medication before as adverse events and respiratory depression can occur.

NUR2225 (9 decks)

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