Wk 2: Metal health assessment Flashcards

Question

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

Answer 1

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)

Answer 2

- 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

Answer 3

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:

Answer 4

= 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

Answer 5

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)

Answer 6

= misinterpretation of external stimuli

Answer 7

= person feels as if they don't exist

Answer 8

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

Answer 9

= 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

Answer 10

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

Answer 11

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

Answer 12

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

Answer 13

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

Answer 14

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

Answer 15

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

Answer 16

- 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

Answer 17

- 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

Answer 18

- 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

Answer 19

- 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

Answer 20

- 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)

Answer 21

- 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

Answer 22

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.

Answer 23

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

Answer 24

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

Answer 25

= 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.

Answer 26

Risk to self Risk to others Risk by/from others Iatrogenic risks (risks associated with engaging with the MH system) -

Answer 27

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’

Answer 28

- 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)

Answer 29

- 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

Answer 30

=(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

Answer 31

- what is the likelihood of this risk occurring? - is the risk imminent or delayed - if it happened, what is the severity?

Answer 32

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

Answer 33

- do u have a plan? time? date? - what is the method? - lethality of the methods? Ask about protective factors

Answer 34

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)

Answer 35

- 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

Answer 36

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’)

Answer 37

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

Answer 38

- 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

Answer 39

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

Answer 40

= 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

Answer 41

= 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) 2. 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)

Answer 42

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.

Answer 43

= 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.

Answer 44

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.

Wk 2: Metal health assessment Flashcards

(68 cards)