ATI Mental Health CMS
Chapter 1; Basic Mental Health Nursing Concepts
→ Assessment
Mental Status Exam (MSE)
1) Level of consciousness:
- Alert
- Lethargic: client can open eyes and respond but is drowsy and falls asleep quickly
- Stuporous: client requires vigorous and painful stimuli to elicit brief
response
- Comatose: unconscious & does not respond to painful stimuli
Abnormal posturing in comatose client
Decorticate rigidity; flexion & internal rotation of upper extremity joints & legs
Decerebrate rigidity; neck & elbow extension, wrist & finger flexion
2) Physical appearance
3) Behavior
- Mood: emotion that she is feeling
- Affect: objective expression of mood, such as flat affect or lack of facial expression
4) Cognitive & intellectual abilities: orientation, memory, knowledge, calculation, illness perception, judgment, spee
- Immediate memory; repeat series of numbers or list
- Recent memory: visitors from current day, purpose of current appt
- Remote memory: fact from past, DOB, mothers name
→ Considerations Across The Lifespan
Children & Adolescents
- Assessment includes temperament social and environmental factors cultural and religious concerns and
developmental level. the client should be the source of the information but with children and adolescents
caregivers can also provide valuable information.
- Mentally healthy children and adolescents trust others view the world as safe accurately interpret their
environments master developmental tasks and use appropriate coping skills
HEADSSS standardized assessment tool
Home environment;
Education/employment;
Activities;
Drug/ substance abuse;
Sexuality;
Suicide/depression;
Safety
→Mental Health Diagnoses
• The Diagnostic & Statistical Manual of Mental Disorders 5th Edition (DSM-5)
- Used by mental health professionals
- establishes diagnostic criteria for mental health disorders
- identifies expected findings for mental health disorders
- used by nurses to plan implement and evaluate care for clients who have mental health disorders
• Serious Mental Illness
- Includes disorders classified as severe and persistent mental illnesses
- Clients often have difficulty with activities of daily living
- Are lifelong disorders that can have remissions and exacerbations
,→ Therapeutic Strategies in The Mental health Setting
• Counseling; using therapeutic communication skills, assisting with problem solving, crisis intervention,
and stress management
• Milieu therapy; orienting the client to the physical setting, identifying rules and boundaries of the
setting, ensuring a safe environment for the client, and assisting the client to participate in appropriate
activities
• Promotion of self-care activities; helping with self-care task, allowing time for the client to complete
self-care task, and setting incentives to promote client self-care
• Psychobiological interventions; administering prescribed medications, providing teaching to the client
and family about medications, and monitoring for adverse effects and effectiveness of pharmacological
therapies
• Cognitive & behavioral therapies; modeling, operant conditioning, systemic disinvitation
• Health teaching; teaching social & coping skills
• Health promotion & maintenance
• Case management; coordinate holistic care to include medical, mental health, & social services
Chapter 2; Legal & Ethical Issues
→ Legal rights of Clients in Mental Health Setting
Same civil rights as any other citizen including;
- the right to humane treatment and care - confidentiality
- right to vote - written plan of care, participation, and
- rights r/t granting, forfeiture, or denial of discharge follow up
driver’s license - right to communicate with others outside
- right to due process of law including right to facility
press charges - psychiatric advanced directive
- right to consent & refuse treatment
→ Ethical Issues
Bioethics; ethical dilemmas regarding patient care
Beneficence: quality of doing good
Autonomy; right to make own choices
Justice; fair & equal treatment
Fidelity: loyalty & faithfulness to client and own duty
Veracity; honesty
→ Types of Admission to Mental Health Facility
Criteria for involuntary admission;
- presence of mental illness
- danger to self or others
- demonstrates severe disability or inability to meet basic needs
- requires treatment but unable to seek it r/t impact of mental illness
Number of physicians required to certify clients conditions varies (usually 2)
Limited to 60 days
Still considered competent and have the right to refuse.
→ Clients Rights w/ Seclusion & Restraint
When a nurse has tried all other less restrictive means to prevent a client from harming self or others the
following must occur in order to use seclusion or restraint;
- Prescriber must prescribe seclusion or restrain in writing
, - Time limits based on age; 18+ (4 hr.), 9-17 (2 hr.), </=8 (1 hr.); if need continues provider must assess
and rewrite order specifying type of restraint every 24 hours\
- Complete documentation every 15-30 min including description of precipitating events/behavior,
alternative action take, time treatment began, current behaviors foods/fluid provided, vital signs,
medications, time of release
- Restraint or seclusion must be discontinued when the client is exhibiting behavior that is safer and
quieter
** the nurse can use seclusion or restraints without obtaining a providers written prescription only in the case of
emergency ; nurse must then obtain the written prescription within a specified time period usually 15 to 30
minutes
→ Tort Law
Tort; civil wrongdoing
• Intentional Tort; willingly actions that damage clients property or violate rights
- Assault; making threat to clients person, or implied threat
- Battery; touching in harmful or offensive way
**A before B
• Unintentional Tort; actions or inactions that cause unintended harm as result of failing to meet duty in
care
- Negligence; failing to provide adequate care in a personal or professional situation when one has an
obligation to do so; to be liable for negligence it must be proven that the professional had a duty to
protect, breached the duty, that the action or failure to act caused injury, that the injury would not have
happened anyway, and that the damage occurred
- Malpractice; type of professional negligence
→ Documentation
Nurses should document the following r/t violent or unusual episodes;
- Client behavior; clear & objective
- Staff response w/ timelines; too disruptive, violent, or potentially harmful behaviors
- Time provider was notified & and prescriptions received
Chapter 3; Effective Communication
→ Basic Communication
Intrapersonal communication; “self-talk”; occurs within individual
Interpersonal communication; one-on-one communication
• Verbal Communication; Vocab, Denotative/Connotative Meaning, Clarity/ Brevity, Timing/Relevance,
Pacing, Intonation
• Nonverbal Communication; Appearance, Posture, Gait, Face Expression, Eye Contact, gesture, Sounds,
territoriality, Personal Space, Silence
→ Effective Communication Skills & Techniques
• Silence; silence is OK! Allows time for meaningful reflection
• Active Listening; able to hear, observe, & understand
• Questions; able to obtain specific or additional information
- Open ended; facilitates spontaneous response & interactive discussion
- Closed ended; helpful if used sparingly during initial interaction to obtain specific data; avoid using
repeatedly as can block communication
- Projective; uses “what if” or similar questions to explore feelings & gain insight
Chapter 1; Basic Mental Health Nursing Concepts
→ Assessment
Mental Status Exam (MSE)
1) Level of consciousness:
- Alert
- Lethargic: client can open eyes and respond but is drowsy and falls asleep quickly
- Stuporous: client requires vigorous and painful stimuli to elicit brief
response
- Comatose: unconscious & does not respond to painful stimuli
Abnormal posturing in comatose client
Decorticate rigidity; flexion & internal rotation of upper extremity joints & legs
Decerebrate rigidity; neck & elbow extension, wrist & finger flexion
2) Physical appearance
3) Behavior
- Mood: emotion that she is feeling
- Affect: objective expression of mood, such as flat affect or lack of facial expression
4) Cognitive & intellectual abilities: orientation, memory, knowledge, calculation, illness perception, judgment, spee
- Immediate memory; repeat series of numbers or list
- Recent memory: visitors from current day, purpose of current appt
- Remote memory: fact from past, DOB, mothers name
→ Considerations Across The Lifespan
Children & Adolescents
- Assessment includes temperament social and environmental factors cultural and religious concerns and
developmental level. the client should be the source of the information but with children and adolescents
caregivers can also provide valuable information.
- Mentally healthy children and adolescents trust others view the world as safe accurately interpret their
environments master developmental tasks and use appropriate coping skills
HEADSSS standardized assessment tool
Home environment;
Education/employment;
Activities;
Drug/ substance abuse;
Sexuality;
Suicide/depression;
Safety
→Mental Health Diagnoses
• The Diagnostic & Statistical Manual of Mental Disorders 5th Edition (DSM-5)
- Used by mental health professionals
- establishes diagnostic criteria for mental health disorders
- identifies expected findings for mental health disorders
- used by nurses to plan implement and evaluate care for clients who have mental health disorders
• Serious Mental Illness
- Includes disorders classified as severe and persistent mental illnesses
- Clients often have difficulty with activities of daily living
- Are lifelong disorders that can have remissions and exacerbations
,→ Therapeutic Strategies in The Mental health Setting
• Counseling; using therapeutic communication skills, assisting with problem solving, crisis intervention,
and stress management
• Milieu therapy; orienting the client to the physical setting, identifying rules and boundaries of the
setting, ensuring a safe environment for the client, and assisting the client to participate in appropriate
activities
• Promotion of self-care activities; helping with self-care task, allowing time for the client to complete
self-care task, and setting incentives to promote client self-care
• Psychobiological interventions; administering prescribed medications, providing teaching to the client
and family about medications, and monitoring for adverse effects and effectiveness of pharmacological
therapies
• Cognitive & behavioral therapies; modeling, operant conditioning, systemic disinvitation
• Health teaching; teaching social & coping skills
• Health promotion & maintenance
• Case management; coordinate holistic care to include medical, mental health, & social services
Chapter 2; Legal & Ethical Issues
→ Legal rights of Clients in Mental Health Setting
Same civil rights as any other citizen including;
- the right to humane treatment and care - confidentiality
- right to vote - written plan of care, participation, and
- rights r/t granting, forfeiture, or denial of discharge follow up
driver’s license - right to communicate with others outside
- right to due process of law including right to facility
press charges - psychiatric advanced directive
- right to consent & refuse treatment
→ Ethical Issues
Bioethics; ethical dilemmas regarding patient care
Beneficence: quality of doing good
Autonomy; right to make own choices
Justice; fair & equal treatment
Fidelity: loyalty & faithfulness to client and own duty
Veracity; honesty
→ Types of Admission to Mental Health Facility
Criteria for involuntary admission;
- presence of mental illness
- danger to self or others
- demonstrates severe disability or inability to meet basic needs
- requires treatment but unable to seek it r/t impact of mental illness
Number of physicians required to certify clients conditions varies (usually 2)
Limited to 60 days
Still considered competent and have the right to refuse.
→ Clients Rights w/ Seclusion & Restraint
When a nurse has tried all other less restrictive means to prevent a client from harming self or others the
following must occur in order to use seclusion or restraint;
- Prescriber must prescribe seclusion or restrain in writing
, - Time limits based on age; 18+ (4 hr.), 9-17 (2 hr.), </=8 (1 hr.); if need continues provider must assess
and rewrite order specifying type of restraint every 24 hours\
- Complete documentation every 15-30 min including description of precipitating events/behavior,
alternative action take, time treatment began, current behaviors foods/fluid provided, vital signs,
medications, time of release
- Restraint or seclusion must be discontinued when the client is exhibiting behavior that is safer and
quieter
** the nurse can use seclusion or restraints without obtaining a providers written prescription only in the case of
emergency ; nurse must then obtain the written prescription within a specified time period usually 15 to 30
minutes
→ Tort Law
Tort; civil wrongdoing
• Intentional Tort; willingly actions that damage clients property or violate rights
- Assault; making threat to clients person, or implied threat
- Battery; touching in harmful or offensive way
**A before B
• Unintentional Tort; actions or inactions that cause unintended harm as result of failing to meet duty in
care
- Negligence; failing to provide adequate care in a personal or professional situation when one has an
obligation to do so; to be liable for negligence it must be proven that the professional had a duty to
protect, breached the duty, that the action or failure to act caused injury, that the injury would not have
happened anyway, and that the damage occurred
- Malpractice; type of professional negligence
→ Documentation
Nurses should document the following r/t violent or unusual episodes;
- Client behavior; clear & objective
- Staff response w/ timelines; too disruptive, violent, or potentially harmful behaviors
- Time provider was notified & and prescriptions received
Chapter 3; Effective Communication
→ Basic Communication
Intrapersonal communication; “self-talk”; occurs within individual
Interpersonal communication; one-on-one communication
• Verbal Communication; Vocab, Denotative/Connotative Meaning, Clarity/ Brevity, Timing/Relevance,
Pacing, Intonation
• Nonverbal Communication; Appearance, Posture, Gait, Face Expression, Eye Contact, gesture, Sounds,
territoriality, Personal Space, Silence
→ Effective Communication Skills & Techniques
• Silence; silence is OK! Allows time for meaningful reflection
• Active Listening; able to hear, observe, & understand
• Questions; able to obtain specific or additional information
- Open ended; facilitates spontaneous response & interactive discussion
- Closed ended; helpful if used sparingly during initial interaction to obtain specific data; avoid using
repeatedly as can block communication
- Projective; uses “what if” or similar questions to explore feelings & gain insight
