Mental Health Exam 2
Depression
Define common symptoms
Anergia (loss of energy), hopelessness, difficult making decisions
Beck’s Cognitive Triad (p. 199)
3 automatic negative thoughts - responsible for the development of depression
o 1) negative, self-deprecating view of self:
o 2) pessimistic view of the world:
o 3) Belief that negative reinforcement will continue
(no validation for the self)
Risk for suicide- Questions to ask,
High vs low risk (Ch 23)
o High risk:
Potential lethal suicide attempt or persistent ideation with strong
internet or suicide rehearsal
Interventions: admission generally indicated unless a significant
change reduces risk, suicide precautions
o Low risk:
Risk/Protective factor: modified risk factors, strong protective
factors
Suicidality: thoughts of death, no plan, intent or behavior
Interventions: Outpatient referral, symptoms reduction.
-Give emergency/crisis numbers
o Identify current feeling states
o 2. Ask directly “Are you thinking of, or have you been thinking of, killing
yourself”
If they answer yes then ask about the frequency, duration and
intensity on scale 1-10
o 3. Ask if the person has a plan: “When you think about suicide, do you
have a way you might do it?”
o 4. Determine the lethality of the plan
How lethal is the plan, how detailed is it, does the person have a
gun?
o 5. Gather information about risk factors
Age, sex, medical problems, emotional distress, psychiatric
problems, use of drugs, etc
o 6. If there is a history of suicide attempt assess
Intent, lethality and injury
o 7. Consult with one or more professionals and collaboratively
develop a safety plan with the patient
o 8. If the patient is to be managed as an outpatient, also assess:
, Mental Health Exam 2
Social supports, significant others knowledge of signs of potential
suicidal ideation and provision of safety resources
Nursing Diagnosis (Table 15-2)(pg 206)
o Risk for suicide, self-mutilation
o Decisional conflict/Impaired memory/Acute confusion
o Ineffective coping/interrupted family process/risk for impaired parent
attachment
o Hopelessness/Powerless
o Chronic low self-esteem
o Impaired social interaction
o Imbalanced nutrition: less than body requirements
o Constipation
o Sexual dysfunction
Communication Interventions (Table 15-4)
o Help the patient question underlying assumptions and beliefs and consider
alternative explanations to problems
o Work with the patient to identify cognitive distortions that encourage negative
self-appraisal
· Example: Overgeneralizations, Self-blame, mind reading,
discontinuing of positive attitude
o Discuss physical activities the patient enjoys (e.g., running, weightlifting).
Explain that initially 10 to 15 minutes a day 3 or 4 times a week has short-term
benefits.
o Encourage formation of supportive relationships, such as through support
groups, therapy, and peer support.
o Provide information referrals, when needed, for spiritual/religious information
(e.g., readings, programs, tapes, community resources).
· Physical Interventions (Table 15-5)
o Nutrition—Anorexia
· Offer small, high-calorie, and high-protein snacks frequently
throughout the day and evening.
· Offer high-protein and high-calorie fluids frequently throughout the
day and evening.
· When possible, encourage family or friends to remain with the patient
during meals.
· Ask the patient which foods or drinks he or she likes. Offer choices.
Involve the dietitian.
· Weigh the patient weekly and observe the patient’s eating patterns.
o Sleep-Insomnia
· Provide periods of rest after activities
· Encourage the patient to get up and dress and to stay out of bed
during the day
· Encourage the use of relaxation measures in the evening
· Reduce environmental and physical stimulants in the evening
o Self-Care Deficits
· Encourage the use of toothbrush, washcloth, soap, makeup, shaving
equipment and so forth
· When appropriate, give step by step reminders such as, “wash the
right side of your face, now the left.”
Depression
Define common symptoms
Anergia (loss of energy), hopelessness, difficult making decisions
Beck’s Cognitive Triad (p. 199)
3 automatic negative thoughts - responsible for the development of depression
o 1) negative, self-deprecating view of self:
o 2) pessimistic view of the world:
o 3) Belief that negative reinforcement will continue
(no validation for the self)
Risk for suicide- Questions to ask,
High vs low risk (Ch 23)
o High risk:
Potential lethal suicide attempt or persistent ideation with strong
internet or suicide rehearsal
Interventions: admission generally indicated unless a significant
change reduces risk, suicide precautions
o Low risk:
Risk/Protective factor: modified risk factors, strong protective
factors
Suicidality: thoughts of death, no plan, intent or behavior
Interventions: Outpatient referral, symptoms reduction.
-Give emergency/crisis numbers
o Identify current feeling states
o 2. Ask directly “Are you thinking of, or have you been thinking of, killing
yourself”
If they answer yes then ask about the frequency, duration and
intensity on scale 1-10
o 3. Ask if the person has a plan: “When you think about suicide, do you
have a way you might do it?”
o 4. Determine the lethality of the plan
How lethal is the plan, how detailed is it, does the person have a
gun?
o 5. Gather information about risk factors
Age, sex, medical problems, emotional distress, psychiatric
problems, use of drugs, etc
o 6. If there is a history of suicide attempt assess
Intent, lethality and injury
o 7. Consult with one or more professionals and collaboratively
develop a safety plan with the patient
o 8. If the patient is to be managed as an outpatient, also assess:
, Mental Health Exam 2
Social supports, significant others knowledge of signs of potential
suicidal ideation and provision of safety resources
Nursing Diagnosis (Table 15-2)(pg 206)
o Risk for suicide, self-mutilation
o Decisional conflict/Impaired memory/Acute confusion
o Ineffective coping/interrupted family process/risk for impaired parent
attachment
o Hopelessness/Powerless
o Chronic low self-esteem
o Impaired social interaction
o Imbalanced nutrition: less than body requirements
o Constipation
o Sexual dysfunction
Communication Interventions (Table 15-4)
o Help the patient question underlying assumptions and beliefs and consider
alternative explanations to problems
o Work with the patient to identify cognitive distortions that encourage negative
self-appraisal
· Example: Overgeneralizations, Self-blame, mind reading,
discontinuing of positive attitude
o Discuss physical activities the patient enjoys (e.g., running, weightlifting).
Explain that initially 10 to 15 minutes a day 3 or 4 times a week has short-term
benefits.
o Encourage formation of supportive relationships, such as through support
groups, therapy, and peer support.
o Provide information referrals, when needed, for spiritual/religious information
(e.g., readings, programs, tapes, community resources).
· Physical Interventions (Table 15-5)
o Nutrition—Anorexia
· Offer small, high-calorie, and high-protein snacks frequently
throughout the day and evening.
· Offer high-protein and high-calorie fluids frequently throughout the
day and evening.
· When possible, encourage family or friends to remain with the patient
during meals.
· Ask the patient which foods or drinks he or she likes. Offer choices.
Involve the dietitian.
· Weigh the patient weekly and observe the patient’s eating patterns.
o Sleep-Insomnia
· Provide periods of rest after activities
· Encourage the patient to get up and dress and to stay out of bed
during the day
· Encourage the use of relaxation measures in the evening
· Reduce environmental and physical stimulants in the evening
o Self-Care Deficits
· Encourage the use of toothbrush, washcloth, soap, makeup, shaving
equipment and so forth
· When appropriate, give step by step reminders such as, “wash the
right side of your face, now the left.”
