NUR 362 Exam 4 PDF

Mental Health - What is mental health? - Includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every...

Mental Health - What is mental health? - Includes our emotional, psychological, and social well-being. It affects how we think, feel, and act. It also helps determine how we handle stress, relate to others, and make choices. Mental health is important at every stage of life, from childhood and adolescence through adulthood - Statistics - Mental health disorders affect almost 50 million adults in the US - Only about 35 million obtain treatment - 1 in 6 young people experience a major depressive episode - 1 in 20 Americans lived with a serious mental illness such as schizophrenia, bipolar disorder or major depression - Suicide is the 10th leading cause of death in the US and the second leading cause of death in children and adolescents - Primary care clinicians are often the first encounter - Mental Health Symptoms - Psychological - Mental - Emotional - Physical - Pain - Fatigue - Palpitations - Risk Factors: Biopsychosocial Model - Biological: genetics, brain chemistry, chronic illness - Environmental Factors: stress, living arrangement, work - Life experiences: trauma, abuse/neglect, loss/grief, substance abuse - Indications for Mental Health Assessment/Screening - Unexplained physical symptoms - Multiple physical or somatic symptoms - Chronic pain - Recent stress - A reported difficult encounter - Low self-rating of overall health - High use of healthcare services - Substance abuse - ROS - Changes in attention, mood, or speech - Changes in insight, orientation, or memory - Anxiety, panic, ritualistic behavior, and phobias - Delirium or dementia - Components of Mental Health Assessment - Appearance & Behavior - Level of Consciousness  - Posture and motor behavior - Dress, grooming, and personal hygiene - Facial expression - Manner, affect, and relationship to people or things - Speech & Language - Quantity – talkative or unusually silent - Rate - fast or slow - Volume - loud or soft - Fluency - rate, flow, and rhythm; monotone - Articulation - clear or nasal quality - Evaluation of Aphasia (loss of ability to understand or express speech) - Word Comprehension - Ask patient to follow 1 stage command - “Point to your nose” - Repetition - Repeat a phrase – 1 syllable words - No ifs, ands, or buts - Naming - Ask patient to name parts of a watch - Reading Comprehension - Ask patient to read a paragraph out loud - Writing - Ask patient to write a sentence - Mood & Affect - Mood: sustained emotion that encompasses the patient’s perception of the world; what the patient is feeling - Ask patient to describe how they feel - Mood can range from anger, indifference, sadness, contentment, joy, euphoria, or anxious - Affect: pattern of observable behaviors that express subjective feelings/emotions - Range of restricted, blunt, and flat - Observe tone of voice, facial expressions, demeanor - Thoughts & Perceptions - Is the thought process logical, relevant, organized, and coherent? - Thought Content: compulsions, obsessions, phobias, anxieties - Perception: delusions (fixed false belief), hallucinations (actual sensory perception(s) that the patient is feeling that is not there - Insight & Judgement: are decisions and actions based on reality? - Cognitive Functions - Orientation: person, place, time, situation - Attention: serial 7’s, spelling “world” backwards  - Memory: digital span, remote (birthdays), recent (today’s weather), new learning ability (give 3 words and have the patient repeat after a few minutes) - Higher Cognitive Functions - Information & Vocabulary - Ask about work, hobbies, current events - Start with simple questions and move to more difficult - Note choices of vocabulary, grasp of information - Calculating Ability - Addition, multiplications - Abstract Thinking - Proverbs - What does this proverb mean? The squeaky wheel gets the grease - Similarities - How are the following alike? Apple and orange; piano and violin - Constructional Ability: have patient copy a figure or draw a clock - Dementia - Major cognitive disorder - Marked by memory disorders - Personality changes - Impaired reasoning - Delirium - Presents in varying states (hypo vs hyper) - Symptoms fluctuate - Temporary changes related to metabolic or structural brain alteration (meds, infection, environment, etc) Clinical Features Delirium Dementia Onset Acute Insidious Course Fluctuating, with lucid Slowly progressive intervals; worse at night Duration Hours to weeks Months to years Sleep/Wake Cycle Always disrupted Sleep fragmented General Medical Illness or Either or both present Often absent, especially in Drug Toxicity Alzheimer’s Disease - Confusion Assessment Method (CAM) 1. Altered Mental Status or Fluctuating Course 2. Inattention - “Squeeze my hand when I say the letter ‘A’” - Read the following sequences of letters: SAVEAHAART  - ERRORS: No squeeze with ‘A’ & squeeze on letter other than A - If unable to complete letters → pictures 3. Altered Level of Consciousness - Current RASS leveRASS other than zero 4. Disorganized thinking - Will a stone float on water? - Are there fish in the sea? - Does one pound weigh more than two? - Can you use a hammer to pound a nail? - Command: “hold up this many fingers” or “now do the same thing with the other hand” or “add one more finger” - SLUMS Exams - St. Louis University Mental Status Exam - Detection of mild cognitive impairment - Used for geriatric patients in assessing for dementia - Also utilized for patients receiving electroconvulsive therapy (ECT - changes neuropathways and effects neurotransmitters) - Health Promotion & Counseling - Mental Status Exam is generalized screening that can help point you in the direction of a more specialized screening assessment - GAD-7: Generalized Anxiety Disorder Screening Tool - PC-PTSD-5: Primary Care PTSD Screening Tool - PHQ-9: Depression Screening Tool - Suicidal Ideation Screening Tool - Universal Screening for Substance Use Disorders - Screening for Depression & Suicidality – ask your patient: - Over the past 2 weeks have you felt down, depressed, or hopeless? - Over the past 2 weeks have you felt little interest or pleasure in doing things? - Screening for Anxiety – ask your patient: - Over the past 2 weeks, have you been feeling nervous, anxious, or on edge? - Over the past 2 weeks, have you been unable to stop or control worrying? - Over the past 2 weeks have you had an anxiety attack – suddenly feeling fear or panic? - Substance Use Disorders: including alcohol & prescription drugs - The Cage Questionnaire is the most widely used screening tool and includes questions about: Cutting down, Annoyance when criticized, Guilty feelings, Eye opener - One technique is to include, “or drugs” to each question to identify issues with illicit drug use - CIWA (Clinical Institute Withdrawal Assessment for Alcohol) - Assessment for patients who may be exhibiting signs of withdrawal - Order parameters set for a score greater than 8  - Will receive a benzodiazepine (Ativan) to help treat withdrawal symptoms - Common Interventions - Therapy - Cognitive behavioral therapy (CBT) - Dialectical behavior therapy (DBT) - Medications - Antidepressants (SSRI/SNRIs) - Antianxiety (SSRI/Benzos) - Antipsychotics – have lots of side effects - Mood stabilizers – for bipolar disorder - Inpatient Specific – the following are the nurses call - Supine hold - always face up to ensure breathing - Seclusion - peds unit to reduce self harm (if younger than 8 = 30 min; ages 9-17 = 1 hour; age 18+ = 2-4 hours) - Restraint – 4-5 point restraint or none - If a patient is in a restraint they do not have the right to refuse - Patient Safety (always the priority) - Recognizing mental illness is important - Establish trust and be aware of own biases - Ensure proper documentation of findings - Any positive finding should elicit follow-up with a provider and/or emergency services when indicated Pediatrics - General Principles of Child Development 1. Child development proceeds along a predictable pathway 2. The range of normal development is wide 3. Various physical, social, and environmental factors, as well as diseases can affect child development and health 4. The child’s developmental level affects how you conduct the history and physical exam - Obtaining A Health History - Provides the nurse with a full picture of the patient’s: - Current health problems - Past history - Family history - Health patterns - Risk factors (ex. Prenatal care) - Growth and development (are they meeting milestones?) - Obtaining A Health History On A Child - Birth History: gestational age, birth issues, maternal health - Family History: structure, health history, genetics - Medical History: allergies, medications/herbal substances, illnesses, surgical procedures  - Health Maintenance: immunization, OTC medications, herbal therapy, safety and risk factors - Growth & Development - Infants - Birth to one year - Develops trust as physiological and emotional needs are met by the caretakers - Likes routine schedules - Soothed by sucking, swaddling and familiar voices - Excessive handling is not recommended - Physical Exam - Approach the infant gradually & reduce stimulation - Perform as much of the exam as possible with the infant in the parent’s lap - Use mobiles and toys for distraction - No head to toe - Developmental Milestones - Physical development is faster during infancy than any other time - Vital signs - HR, RR, Temp higher than what we know as normal - Systolic BP is lower - Skin - Normal skin: clean, dry, and intact with pink and warm extremities - Assess for pallor, jaundice, cyanosis, rashed, & birthmarks - Jaundice/Hyperbilirubinemia - Yellowing of the skin, sclera, nails, palms, or soles cause by the buildup of bilirubin in the blood, and other tissues or fluids - Bilirubin: a byproduct from the breakdown of RBCs - It is normal for babies to excess RBCs from their mother after birth - How can bilirubin be decreased? → increase feeding, increasing stooling - Benign Birthmarks - Eyelid patch - Salmon patch – “stork bite” → will go away - Cafe-au-lait-spot → doesn't go away - Congenital Dermal Melanocytosis → bruise looking, often in dark skin babies - HEENT - Head: - Normal: equal symmetry, soft, round  - Abnormal: hydrocephalus (fluid in brain), macrocephaly (large head), microcephaly (small head), plagiocephaly (flat spot on head – caused by laying in one place too long) - *head circumferences are measured up to 2 years of age to make sure the head is growing normally - Head Strength - By 4 months: able to lift head and front part of their chest with weight on arms - By 6 months: head lag should be absolutely gone - Sutures & Fontanelles - Anterior Fontanel: closes at 12-18 months - Posterior Fontanel: closes at 6-8 weeks - Abnormal Findings: sunken or bulging fontanelles (should be flat), overriding or separated sutures - Eyes - Assess pupil size; red reflex; appearance of conjunctiva, sclera, and eyelid; eye movement, and spacing between eyes - Genetic syndromes often cause unusual eye shape - Visual Acuity cannot be measured - At 1 month, most infants can fixate on an object - At 2 months, most infants can follow an object - At 3 months, most infants can reach towards a visual stimulus - Hearing - Assess shape, size, position - Genetic syndromes often cause unusual ear shape/position - Infant ear canals are directed downward - 0-2 months: startle response and blink to sudden noise; calming down with soothing voice or music - 2-3 months: change in body movements in response to sound; change in facial expression to familiar sounds - 3-4 months: turning eyes and head to sound - 6-7 months: turning to listen to voices and conversation; appropriate language development (trying to imitate you) - Respiratory - Assess respirations, expansion, & breathing patterns - Count respirations for a full minute - Normal: 30-60 breaths/minute, clear and equal breath sounds - Abnormal: >60, nasal flaring, retractions, grunting, audible wheezing, no breath sounds, cyanosis, stridor - *infants are nose breathers - *may have periods of apnea  - *retractions are a sign of respiratory distress - Cardiovascular - Assess heart rhythm, pulses, skin color, capillary refill, heart sounds - Normal: normal sinus rhythm, cap refill < 3 seconds, pink warm skin, normal pulses - Abnormal: cap refill > 3 seconds, cyanotic skin, bounding or weak pulses, heart murmurs - Gastrointestinal - Assess for hernias and distention (is the hernia reducible?) - Auscultate bowel sounds - Palpate for masses and abdominal organs - Ask parents about bowel patterns - Normal: tinkling bowel sounds heard in all 4 quadrants, non-tender, 6-10 wet diapers/day - Abnormal: hypoactive or absent bowel sounds, hard masses upon palpation, no stools in > 3 days - Neurological - Assess for: gross and fine motor function, tone, cry, deep tendon reflexes, primitive reflexes - Primitive Reflexes: - Moro (startle) → up to 2 months - Rooting (suck) → up to 4 months - Grasp (palmer and plantar) → up to 5-6 months - Babinski (toes spread) → up to 12 months - Toddlers - 1-3 years old - Play is extremely important - Terrified of strangers, equipment, and strange environments - Animism - Assessment approaches - *care for the child with caregiver help - Allow play time as much as possible - Utilize procedure rooms - Use toys/books/music from home - Preschooler - 3-5 years old - Asks “why” questions - Very concrete: needs to see, feel, touch, & smell - Fear of bodily injury and mutilation - Needs play activity to decrease trauma of hospitalization - Allow role-play with miniature equipment - Tips to Assessing Young Children - Engage the child’s cooperation & encourage a lot of PLAY  - Allow the child to remain dressed for as long as possible and on their parent’s lap - Least invasive to most invasive assessments, saving the throat/ears/genitalia for last - Avoid asking for permission to assess something, instead say “should I listen to your tummy first or listen to your heart first? - Toddler & Preschool Age Children Vital Signs - Getting more normal - Slightly higher than what we consider normal - School Child - 6-12 years old - Sense of industry being developed, enjoys accomplishments - Begins to understand relationships of events, parts, etc - Likes to be heroic, please others and be in control - Adolescents - 12-18 years old - Are very conscious of body image - Contact with peers is important - Becomes isolated if unable to develop intimacy - Think they are immortal - Physical Exam: Children & Adolescents - Skin: - Assess for warts, acne, insect bites, ringworm, rashes, bruises - Exam techniques are similar to the adult assessment - Mouth: - Assess for cavities, mucosal breakdown (leads to infection and sepsis), breath odor - Inspect tonsils, tongue, teeth, palate - MSK: - Scoliosis screening: - Idiopathic scoliosis (75% of cases), seen mostly in girls, is usually detected in early adolescence - Screening for participation in sports - Focuses on cardiovascular health, concussion history, musculoskeletal weakness, limited range of motion, and evidence of previous injury - Sexual Maturity Rating - Females: 1. Breast development 2. Pubic hair growth (some girls experience hair growth before breast development) 3. Axillary hair growth - Males: 1. Testicular enlargement  2. Pubic hair growth 3. Penile enlargement 4. Growth of axillary hair 5. Facial hair growth 6. Vocal changes - Key Components of Pediatric Health Promotion - Every interaction with a child and family is an opportunity for health promotion - Age-appropriate developmental achievement of the child - Physical, motor, cognitive, emotional, social - Immunizations - Anticipatory guidance - Healthy habits, nutrition, self-esteem, safety, sexual development, positive parents strategies, sleep, emotional health, family relationships, oral health, etc. Nursing Communication & Documentation - Sentinel Event - Is a patient safety event that reaches a patient and results in any of the following: death, permanent harm, severe temporary harm and intervention required to sustain life - An event can also be considered a sentinel event if the outcome was not death, permanent harm, severe temporary harm and intervention required to sustain life” - Most common: - Wrong surgery site - Foreign body retention - Falls - Suicide - Delay in treatment - Medication errors - *40% of new nurses will make a medication error due to inexperience - In past: infant discharge to wrong family - Josie King Story - How does communication affect patient care? - Absent, inaccurate, or delayed communication can subject the patient to serious risks or delayed recovery - The Joint Commission identified critical communication failure as one of the most common root causes responsible for sentinel events during 2004-2014 - Types of Communication - Client Interview/Therapeutic Communication - Get as much information as possible - Communication with Client - Phase One: Pre-Interview - Review medical records  - Adjust environment - Phase Two: Introduction - Meet & greet client - Phase Three: Working Phase - Invite client’s story - Respond to cues - Clarify: ask questions - Phase Four: Termination - Summarize - Review and set plan - Communicate with the team - Purpose of Effective Communication - Communicates the plan of care and patient progress to all healthcare team members - Nursing: availability of assessment data allows for an accurate patient plan of care - Conveys clear picture of patient through different viewpoints and at different times - Allows comparison of objective and subjective assessment data gathered by all team members to determine current health status and progress toward goals - Ensures continuity of care and provides data for continuation of care - Nurse Handoffs - Occurs any time one provider transfers the responsibility and accountability for the care of a patient to another - A Joint Commission National Patient Safety Goal is that all agencies have a standardized approach (template) to handoff communications - What is a handoff? - A hand off is a transfer and acceptance of patient care responsibility achieved through effective communication - It is a real time process of passing specific information from one caregiver to another or from one team of caregivers to another for the purpose of ensuring the continuity and safety of the patient’s care - Improves patient safety - Reduces harm - Improves patient experience - Increases nursing satisfaction - Improves nursing collaboration - Improves time management - Improves nursing accountability - Nurse to Nurse Handoff - DATAS - Descriptive sentence - Active issues  - To-do list - Anticipatory guidance - Special circumstances - Nurse to Provider Handoff - Usually for something that is abnormal - iSBAR - identify yourself: who is sending the information - Who are you and where are you calling from - Who is your patient - Situation: what is happening at the present time - What is the immediate problem/situation - Background: what are the circumstances leading up to the situation - Patient diagnosis and date of admission - Why were they admitted - Pertinent medical information - Medications, allergies, lab results, code status - Pertinent subjective and objective assessment findings - Assessment (assess the scenario): what is the problem/analyze the problem - What do you think is going on - Analysis of the data (subjective/objective) collected - Recommendation: what should be done to correct the problem - What needs to happen - Request or recommend an action - Plan - Nursing Documentation - Principles: Confidentiality - Keeping information private is a legal and an ethical requirement - Applies to written and computerized medical records - The Health Insurance Portability and Accountability Act (HIPAA) regulates all areas of information management, including security of records - Students must de-identify any patient information in written assignments to be HIPAA compliant - Principles: Accuracy - Nursing documentation should only contain observations that nurses have seen, heard, smelled, or felt. Observations or statements by other healthcare professionals need to be identified as such – don’t document what you didn’t do - All information that was charted remains in the patient record; erasure is not permissible - Proofreading should be done to assure correct spelling and correct use of medical terms – professionalism  - Can serve as a legal document of the patient’s health status and care received - Can be included in an audit to ensure quality care - Principles: Concise & Complete - Partial sentences and phrases should be used in narratives - The patient’s name and terms referring to the patient can be eliminated in narrative charting - Only abbreviations that are commonly accepted and approved by the institution should be used - Actual patient behavior should be described rather than making interpretations; use direct quotations when appropriate - If it’s not documented, it didn’t happen! - Types of Nursing Documentation 1. Narrative Note/Progress Note - A nursing narrative note enables nurses to provide a comprehensive description of their patient’s condition, including any changes in body systems and reactions to treatments 2. Electronic Medical Record Flowsheets - Improved access to information - Streamline communication between team - Clients can access their personal information - Reduces duplication and time - Safety (reminders of due/overdue items) - Flowsheets within EMR 3. SOAP Note - Similar to progress note; evaluation of patient - Subjective assessment - Objective assessment - Assessment/Analysis - Plan