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4 nursing priorities

1. safety
2. airway
3. breathing
4. circulation

criteria to diagnose:

1. essential features
2. associated features
3. a specific time frame during which these features have occurred
4. signs and symptoms cause significant impairment to person's ability to fnxn

DSM 5 axes of the multi axial assessment

I. Clinical disorders
II. Personality disorders/intellectual delay
III. General Medical Conditions
IV. Psychosocial and Environmental Problems
V. Global Assessment of Functioning

I. Clinical disorder

-the mental illness being treated
-may have more than one diagnosis
(schizophrenia, depression, etc)

II. Personality Disorders or Intellectual Delay

-more stable characteristics, unchanging
-their personality and intellectual capacity
(intellectual delay, borderline, antisocial)

III. General Medical conditions

HTN, HIV, etc.

IV. Psychosocial Stressors

-problems with family support
-problems R/T social environment
-educational problems
-occupational problems
-poverty

V. Global assessment of functioning

-clinician's subjective rating of how likely the client is to function in society at this moment
-0 to 100

social ecological model of health

defense mechanisms

psychological strategies brought into play by individuals and groups to cope with reality and maintain self image
-protective in nature
-used for overwhelming anxiety
-reactionary and automatic

healthy use of defense mechanisms

-used to integrate conflicting emotions and thoughts while still remaining effective

types of healthy defense mechanisms (4)

1. altruism
2. anticipation
3. identification
4. suppression

altruism

constructive service to others that brings pleasure and the personal satisfaction and is not compensatory

anticipation

realistic planning for future discomfort

identification

unconscious modeling of one's self upon another person's or group's character and behavior

suppression

-pushing thoughts into the preconscious short term, for coping at the present time
-you are aware that you are doing this, and you are able to come back and address the thoughts

denial

refusing to accept or believe reality

repression

in psychoanalytic theory, the basic defense mechanism that banishes from consciousness anxiety-arousing thoughts, feelings, and memories

reaction formation

-behave in a way that is the exact opposite of your true feelings
ex: Jane hates nursing but attended school to please her parents and speaks about the excellence of her career

projection

a defense mechanism by which your own traits and emotions are attributed to someone else
-you are attracted to someone else and tell your friends "he is coming on to me"

rationalization

justifying personal actions by giving "rational" but false reasons for them

displacement

diverting emotional feelings (usually anger) from their original source to a substitute target

identification

bolstering self-esteem by forming an imaginary or real alliance with some person or group

compensation

covering up felt weaknesses by emphasizing some desirable characteristic, or making up of frustration in one area by over-gratifying another

undoing

-atoning for or trying to magically dispel unacceptable desires or acts
-the actual issue isn't addressed, just nice things are said or done instead

Mental status exam

-collates information about the client's physical, emotional, and cognitive state
-the mental head to toe

MSE: physical (3)

1. appearance
2. behavior
3. motor activity

MSE: emotional (2)

1. attitude
2. mood and affect

MSE: cognitive (8)

1. orientation
2. memory
3. thought
4. insight and judgement
5. attention and concentration
6. speech and language
7. perception
8. intelligence and abstraction

physical appearance

are they put together and groomed?
appropriately dressed?

behavior

are they alert? in a stupor? what are their mannerisms?

motor activity (4)

1. bradykinesia (think Eyore)
2. hypokinesia
3. akinesia
4. psychomotor agitation (think Tigger!)

mood and affect

-affect: external expression of an emotional state
-mood: internal emotional experience that influences perception and actions

incongruence

mismatch btwn mood and affect
(someone who says they are really happy but is talking in a low, depressed sounding voice)

emotional

how stable is their mood?
euphoric, dysphoric, hostile, apprehensive, fearful?

orientation

person, place, time, situation

attention and concentration

-ability to focus
-are they distractible? Do they go off on tangents?
-have them do a digit span or serial sevens

digit span

give them a series of numbers and have them repeat it backwards

serial sevens

have them count backwards from 100 by sevens

memory (3)

1. short term: who is the president?
2. visual short-term: draw something and have them draw it
3. long-term: ask about childhood events

thought (form and content)

how fast are they producing their thinking?
are their thoughts tangental? loose associations?
delusions?

tangental

similar to circumstantial thought, but person never returns to central point nor answers original questions

loose associations

one word in the sentence is related to the next thought

delusion

a false fixed belief despite objective contradictory evidence
-they aren't going to change their mind- just try and redirect the behavior

perception

-are there hallucinations?
-derealization?
-depersonalization?

hallucinations

perceptual disturbance related to the 5 senses
-most usually auditory

derealization

The loss of one's sense of reality of the outside world. Examples: things may seem to change size or shape; people may seem mechanical.

depersonalization

person doesn't feel like they are real

insight and judgement

insight- are they aware they have a problem?
judgement- the ability to make sound decisions

speech and language

is it slow or rapid? aphasia?

aphasia

slurred speech

intelligence and abstraction

do they have a general fund of knowledge? do they have intellectual delay?

abstraction?

abstraction

ability to recognize and comprehend abstract relationships

primary focus of MSE

1. safety
2. affect
3. mood
4. behavior
5. cognition

SOLER

Squarely face client
Open posture
Lean forward
Establish eye contact
Relax

using touch in a mental health setting

be aware of the hypersensitivity of some clients
-they may interpret it as a sexual invitation
-invasion of space

process recording

-a written report of verbal interaction with the client
-paraphrase as best as you can and be sure to include their actions and mannerisms

delirium

-usually temporary or reversible
-often caused by withdrawal, drug abuse, electrolyte imbalance, pneumonia, UTIs, post-op

giving recognition

-therapeutic
-acknowledging and indicating awareness

general leads

-therapeutic
-encourages client to continue
-"yes, I see,"
-"go on..."

making observations

-therapeutic
-verbalizing client behaviors
"you seem tense"

restating

-therapeutic
-lets the client know you are listening and allows for clarification

reflecting

-therapeutic
-questions and feelings are referred back to the client
-good way to avoid giving advice

exploring

-therapeutic
-delving further into subject matter

presenting reality

-therapeutic
-used when a client is having hallucinations, etc, you tell them what you observe

voicing doubt

-therapeutic
-expressing uncertainty in the client's perceptions
"I find that hard to believe"

giving reassurance

-non-therapeutic

rejecting

-non-therapeutic

giving approval or disapproval, giving advice, or agreeing/disagreeing

-non-therapeutic

probing

-non-therapeutic
-persistent questioning of a subject the client doesn't want to discuss

defending

-non-therapeutic
"no one here would lie to you"

requesting an explanation

-non-therapeutic
"why do you think that?"

indicating the existence of an external source of power

-non-therapeutic
-"what makes you say that? What made you do that?"
-allows the client to pass blame

using denial

-non-therapeutic
client says: "i'm nothing"
you say: "of course you are something! Everybody is somebody."

you SHOULD say, "you feel like nobody cares about you right now"

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