Nursing Capstone Review
Cognition, Emotional Processes Mental Health Concepts
Assessment
Appearance, behavior, mood
a. Well groomed, relaxed
b. Self-confident, self-accepting
Cognition, Emotional Processes Mental Health Concepts
Assessment
Speech, thought content, and thought process
a. Clear, coherent
b. Reality-based
Cognition, Emotional Processes Mental Health Concepts
Assessment
Sensorium
a. Oriented to person, place, and time
b. Good memory
c. Ability to abstract
Cognition, Emotional Processes Mental Health Concepts
Insight and Judgement
Accurate self-perception and awareness
Cognition, Emotional Processes Mental Health Concepts
Family relationships and work habits
a. Satisfying interpersonal relationships
b. Ability to trust
c. Ability to cope effectively with stress
d. Environmental mastery
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Potential support systems or stressors
a. Religious organizations or community support
b. Family
c. Socioeconomic resources
,d. Education
e. Cultural norms
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Potential Risk factors
a. Family history of mental illness
b. Medical history—imbalances can cause symptoms resembling emotional illness
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Satisfaction of basic human needs in order of importance (Maslow)
a. Physical—oxygen, water, food, sleep, sex
b. Safety—physical, security, order
c. Love and belonging—affection, companionship, identification
d. Esteem and recognition—status, success, prestige
e. Self-actualization—self-fulfillment, creativity
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Potential Nursing Diagnoses
a. Social interaction, impaired
b. Anxiety
c. Individual coping, ineffective
d. Self-esteem disturbance
Goal/ Purpose
Using Silence
Allows client time to think and reflect; conveys acceptance
Allows client to take lead in
conversation
Goal/ Purpose
Using general leads or broad openings
Encourages client to talk
Indicates interest in client
Allows client to choose subject
Sets tone for depressed client
Goal/ Purpose
Clarification
Encourages recall and details of particular experience
,Encourages description of feelings
Seeks clarification, pinpoints specifics
Makes sure nurse understands client
Goal/ Purpose
Reflecting
Paraphrases what client says
Reflects what client says, especially feelings conveyed
Focus of Treatment
Milieu Therapy
Positive physical and social environment
Structured groups and activities
One-on-one intervention
May be token program, open wards, self-medication
Focus of Treatment
Play Therapy
Provide materials and toys to facilitate interaction with child, observe play, and help child to
resolve problems through play
Operant conditioning
Use of rewards to reinforce positive behavior;
becomes more important than
external reinforcement
Desensitization
used to treat phobias;
client slowly adjusts to threatening objects
Anxiety
Assessment
Cardiovascular
a. Increased pulse, blood pressure, and respiration
b. Palpitations, chest discomfort/pain
c. Perspiration, flushing, and heat sensations
d. Cold hands and feet
e. Headache
Anxiety
Assessment
, GI
a. Nausea, vomiting, and diarrhea
b. Belching, heartburn, cramps
Anxiety
Assessment
Musckuloskeletal
a. Increased muscle tension and tendon reflexes
b. Increased generalized fatigue
c. Tremors, jerking of limbs
d. Unsteady voice
Anxiety
Assessment
Intellectual
a. Poor comprehension—may be unable to follow directions
b. Poor concentration, selective inattention
c. Focus on detail
d. Impaired problem solving
e. Unable to communicate
1) Thoughts may become random, distorted, disconnected with impaired logic
2) Rapid, high-pitched speech
Anxiety
Assessment
Social and Emotional
a. Feelings of helplessness and hopelessness
b. Feelings of increased threat, dread, horror, anger, and rage
c. Use of defense mechanisms and more primitive coping behaviors
1) Shouting, arguing, hitting, kicking
2) Crying, rocking, curling up, and withdrawal
Anxiety
Feeling of dread or fear in the absence of an external threat or disproportionate to the nature
of the threat
Levels of Anxiety
Mild
High degree of alertness, mild uneasiness
Levels of Anxiety
Moderate
Cognition, Emotional Processes Mental Health Concepts
Assessment
Appearance, behavior, mood
a. Well groomed, relaxed
b. Self-confident, self-accepting
Cognition, Emotional Processes Mental Health Concepts
Assessment
Speech, thought content, and thought process
a. Clear, coherent
b. Reality-based
Cognition, Emotional Processes Mental Health Concepts
Assessment
Sensorium
a. Oriented to person, place, and time
b. Good memory
c. Ability to abstract
Cognition, Emotional Processes Mental Health Concepts
Insight and Judgement
Accurate self-perception and awareness
Cognition, Emotional Processes Mental Health Concepts
Family relationships and work habits
a. Satisfying interpersonal relationships
b. Ability to trust
c. Ability to cope effectively with stress
d. Environmental mastery
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Potential support systems or stressors
a. Religious organizations or community support
b. Family
c. Socioeconomic resources
,d. Education
e. Cultural norms
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Potential Risk factors
a. Family history of mental illness
b. Medical history—imbalances can cause symptoms resembling emotional illness
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Satisfaction of basic human needs in order of importance (Maslow)
a. Physical—oxygen, water, food, sleep, sex
b. Safety—physical, security, order
c. Love and belonging—affection, companionship, identification
d. Esteem and recognition—status, success, prestige
e. Self-actualization—self-fulfillment, creativity
Cognition, Emotional Processes Mental Health Concepts
Diagnose
Potential Nursing Diagnoses
a. Social interaction, impaired
b. Anxiety
c. Individual coping, ineffective
d. Self-esteem disturbance
Goal/ Purpose
Using Silence
Allows client time to think and reflect; conveys acceptance
Allows client to take lead in
conversation
Goal/ Purpose
Using general leads or broad openings
Encourages client to talk
Indicates interest in client
Allows client to choose subject
Sets tone for depressed client
Goal/ Purpose
Clarification
Encourages recall and details of particular experience
,Encourages description of feelings
Seeks clarification, pinpoints specifics
Makes sure nurse understands client
Goal/ Purpose
Reflecting
Paraphrases what client says
Reflects what client says, especially feelings conveyed
Focus of Treatment
Milieu Therapy
Positive physical and social environment
Structured groups and activities
One-on-one intervention
May be token program, open wards, self-medication
Focus of Treatment
Play Therapy
Provide materials and toys to facilitate interaction with child, observe play, and help child to
resolve problems through play
Operant conditioning
Use of rewards to reinforce positive behavior;
becomes more important than
external reinforcement
Desensitization
used to treat phobias;
client slowly adjusts to threatening objects
Anxiety
Assessment
Cardiovascular
a. Increased pulse, blood pressure, and respiration
b. Palpitations, chest discomfort/pain
c. Perspiration, flushing, and heat sensations
d. Cold hands and feet
e. Headache
Anxiety
Assessment
, GI
a. Nausea, vomiting, and diarrhea
b. Belching, heartburn, cramps
Anxiety
Assessment
Musckuloskeletal
a. Increased muscle tension and tendon reflexes
b. Increased generalized fatigue
c. Tremors, jerking of limbs
d. Unsteady voice
Anxiety
Assessment
Intellectual
a. Poor comprehension—may be unable to follow directions
b. Poor concentration, selective inattention
c. Focus on detail
d. Impaired problem solving
e. Unable to communicate
1) Thoughts may become random, distorted, disconnected with impaired logic
2) Rapid, high-pitched speech
Anxiety
Assessment
Social and Emotional
a. Feelings of helplessness and hopelessness
b. Feelings of increased threat, dread, horror, anger, and rage
c. Use of defense mechanisms and more primitive coping behaviors
1) Shouting, arguing, hitting, kicking
2) Crying, rocking, curling up, and withdrawal
Anxiety
Feeling of dread or fear in the absence of an external threat or disproportionate to the nature
of the threat
Levels of Anxiety
Mild
High degree of alertness, mild uneasiness
Levels of Anxiety
Moderate
