ATI CMS EXAM REVIEW - MENTAL HEALTH
LOC - ALERT patient is responsive
opens eyes spontaneously
answers questions appropriately
LOC - LETHARGIC patient can open eyes and respond to questions
falls asleep easily
LOC - OBTUNDED patient responds to light shaking
is confused
slow to respond
LOC - STUPOROUS patient barely responds to painful stimuli
example
rubbing sternum
LOC - COMATOSE patient is unresponsive
abnormal posturing may be present
DECORTICATE POSTURING arms flexed/internally rotated
legs extended/internally rotated
DECEREBRATE POSTURING head arched back
arms/legs extended
AUTONOMY patient has the right to make their own decisions even if not in their best interest
BENEFICENCE do what is best for the patient
do good
FIDELITY keep your promises
loyalty/faithfulness
JUSTICE provide fairness in care and allocation of resources
NONMALEFICENCE do no harm
VERACITY tell the truth
, ATI CMS EXAM REVIEW - MENTAL HEALTH
PATIENT RIGHTS - REFUSAL OF TREATMENT even patients who are involuntarily admitted have the right to refuse treatment
PATIENT RIGHTS - CONFIDENTIALITY HIPAA states that health information cannot be released without patient's
permission
client's right to privacy continues even after death
CONFIDENTIALITY - NURSING ACTIONS if someone calls to get an update, suggest they reach out to the patient's family
if you overhear a conversation in a public space, take action to stop the violation
PATIENT RIGHTS - MANDATORY REPORTING nurses are required to report suspicion of abuse
warn/protect third parties who are at risk for harm
INFORMED CONSENT - PROVIDER communicate purpose of procedure
RESPONSIBILITIES
provide a complete description of procedure in patient's primary language (use
interpreter if needed)
explain risks vs. benefits
describe other options to treat condition
INFORMED CONSENT - NURSE/RN make sure provider gave patient appropriate information regarding procedure
RESPONSIBILITIES
ensure that patient is competent to give informed consent
have patient sign consent document
notify provider if patient has more questions or doesn't understand information
provided
RESTRAINTS - TYPES Physical
- vest
- belt
- mitten
Chemical
- sedative Rx
- antipsychotic Rx
RESTRAINTS - ALTERNATIVES provide verbal interventions
diversions
calm/quiet environment
RESTRAINTS - PRESCRIPTIONS MUST BE IN WRITING
prescription must be rewritten every 24 hours
in an emergency situation, a nurse may use restraints, but must obtain a written
prescription per facility policy (usually within 15-30 minutes)
RESTRAINTS - TIME LIMITS Adults
4 hours
Ages 9 - 17
2 hours
Ages 8 and Under
1 hour
, ATI CMS EXAM REVIEW - MENTAL HEALTH
RESTRAINTS - DOCUMENTATION complete every 15-30 minutes
include the following:
- precipitating event
- alternative interventions attempted
- time treatment began
- medication(s) administered
- patient assessment (current behavior, VS, pain)
- patient care provided (food, toileting)
RESTRAINTS - DISCONTINUATION restraints can be discontinued when patient can follow nurse's directions
UNINTENTIONAL TORTS Negligence
forgetting to set bed alarm for a fall risk patient
Malpractice
medication error that harms patient
INTENTIONAL TORTS Assault
nurse threatens patient
Battery
- nurse hits patient
- gives Rx against patient's will
False Imprisonment
- nurse inappropriately restrains a patient
- nurse administers a chemical restraint (Rx)
INTRAPERSONAL COMMUNICATION self-talk
thinking thoughts, but not verbalizing them
INTERPERSONAL COMMUNICATION one-on-one communication with another person
OPEN-ENDED QUESTIONS promotes interactive discussion
example
"tell me more..."
CLOSED-ENDED QUESTIONS used to obtain specific data
use sparingly as it can block communication
*example"
questions that can be answered with a "yes" or "no"
RESTATING repeat the patient's exact words
REFLECTING return focus back to the patient
PARAPHRASING restate patient's feelings to confirm understanding of what patient is saying
EXPLORING gathering more information about something that patient mentioned
, ATI CMS EXAM REVIEW - MENTAL HEALTH
GENERAL LEADS allows patient to guide discussion
PRESENTING REALITY communicate what is actually happening
dispel hallucinations/delusions/disbeliefs
OFFERING SELF limited self-disclosure by nurse
return focus to the patient ASAP
THERAPEUTIC COMMUNICATION - WRONG WAY asking "why" questions
offering your opinion
giving false reassurance
giving advice
changing the subject
minimizing the patient's feelings
THERAPEUTIC COMMUNICATION - RIGHT WAY asking open-ended questions
maintaining eye contact to convey interest
sitting/standing at eye level
therapeutic touch to convey caring/provide comfort
THERAPEUTIC COMMUNICATION - BEST PRACTICE minimize distractions
FOR OLDER ADULTS
discuss health in private setting
face patient when speaking
use lower pitch voice
begin interview by asking the patient to identify their needs/concerns
limit number of items on questionnaire when gathering data
allow plenty of time for patient to respond
DEFENSE MECHANISM - ALTRUISM dealing with stress/anxiety by helping others
DEFENSE MECHANISM - SUBLIMATION substitute negative impulses into acceptable forms of expression
example
working out hard at the gym
DEFENSE MECHANISM - SUPRESSION voluntary denial of unpleasant thoughts/feelings
DEFENSE MECHANISM - REPRESSION unconscious denial of unpleasant thoughts/feelings
DEFENSE MECHANISM - REGRESSION reverting back to childlike behaviors that are inappropriate for current level of
development
LOC - ALERT patient is responsive
opens eyes spontaneously
answers questions appropriately
LOC - LETHARGIC patient can open eyes and respond to questions
falls asleep easily
LOC - OBTUNDED patient responds to light shaking
is confused
slow to respond
LOC - STUPOROUS patient barely responds to painful stimuli
example
rubbing sternum
LOC - COMATOSE patient is unresponsive
abnormal posturing may be present
DECORTICATE POSTURING arms flexed/internally rotated
legs extended/internally rotated
DECEREBRATE POSTURING head arched back
arms/legs extended
AUTONOMY patient has the right to make their own decisions even if not in their best interest
BENEFICENCE do what is best for the patient
do good
FIDELITY keep your promises
loyalty/faithfulness
JUSTICE provide fairness in care and allocation of resources
NONMALEFICENCE do no harm
VERACITY tell the truth
, ATI CMS EXAM REVIEW - MENTAL HEALTH
PATIENT RIGHTS - REFUSAL OF TREATMENT even patients who are involuntarily admitted have the right to refuse treatment
PATIENT RIGHTS - CONFIDENTIALITY HIPAA states that health information cannot be released without patient's
permission
client's right to privacy continues even after death
CONFIDENTIALITY - NURSING ACTIONS if someone calls to get an update, suggest they reach out to the patient's family
if you overhear a conversation in a public space, take action to stop the violation
PATIENT RIGHTS - MANDATORY REPORTING nurses are required to report suspicion of abuse
warn/protect third parties who are at risk for harm
INFORMED CONSENT - PROVIDER communicate purpose of procedure
RESPONSIBILITIES
provide a complete description of procedure in patient's primary language (use
interpreter if needed)
explain risks vs. benefits
describe other options to treat condition
INFORMED CONSENT - NURSE/RN make sure provider gave patient appropriate information regarding procedure
RESPONSIBILITIES
ensure that patient is competent to give informed consent
have patient sign consent document
notify provider if patient has more questions or doesn't understand information
provided
RESTRAINTS - TYPES Physical
- vest
- belt
- mitten
Chemical
- sedative Rx
- antipsychotic Rx
RESTRAINTS - ALTERNATIVES provide verbal interventions
diversions
calm/quiet environment
RESTRAINTS - PRESCRIPTIONS MUST BE IN WRITING
prescription must be rewritten every 24 hours
in an emergency situation, a nurse may use restraints, but must obtain a written
prescription per facility policy (usually within 15-30 minutes)
RESTRAINTS - TIME LIMITS Adults
4 hours
Ages 9 - 17
2 hours
Ages 8 and Under
1 hour
, ATI CMS EXAM REVIEW - MENTAL HEALTH
RESTRAINTS - DOCUMENTATION complete every 15-30 minutes
include the following:
- precipitating event
- alternative interventions attempted
- time treatment began
- medication(s) administered
- patient assessment (current behavior, VS, pain)
- patient care provided (food, toileting)
RESTRAINTS - DISCONTINUATION restraints can be discontinued when patient can follow nurse's directions
UNINTENTIONAL TORTS Negligence
forgetting to set bed alarm for a fall risk patient
Malpractice
medication error that harms patient
INTENTIONAL TORTS Assault
nurse threatens patient
Battery
- nurse hits patient
- gives Rx against patient's will
False Imprisonment
- nurse inappropriately restrains a patient
- nurse administers a chemical restraint (Rx)
INTRAPERSONAL COMMUNICATION self-talk
thinking thoughts, but not verbalizing them
INTERPERSONAL COMMUNICATION one-on-one communication with another person
OPEN-ENDED QUESTIONS promotes interactive discussion
example
"tell me more..."
CLOSED-ENDED QUESTIONS used to obtain specific data
use sparingly as it can block communication
*example"
questions that can be answered with a "yes" or "no"
RESTATING repeat the patient's exact words
REFLECTING return focus back to the patient
PARAPHRASING restate patient's feelings to confirm understanding of what patient is saying
EXPLORING gathering more information about something that patient mentioned
, ATI CMS EXAM REVIEW - MENTAL HEALTH
GENERAL LEADS allows patient to guide discussion
PRESENTING REALITY communicate what is actually happening
dispel hallucinations/delusions/disbeliefs
OFFERING SELF limited self-disclosure by nurse
return focus to the patient ASAP
THERAPEUTIC COMMUNICATION - WRONG WAY asking "why" questions
offering your opinion
giving false reassurance
giving advice
changing the subject
minimizing the patient's feelings
THERAPEUTIC COMMUNICATION - RIGHT WAY asking open-ended questions
maintaining eye contact to convey interest
sitting/standing at eye level
therapeutic touch to convey caring/provide comfort
THERAPEUTIC COMMUNICATION - BEST PRACTICE minimize distractions
FOR OLDER ADULTS
discuss health in private setting
face patient when speaking
use lower pitch voice
begin interview by asking the patient to identify their needs/concerns
limit number of items on questionnaire when gathering data
allow plenty of time for patient to respond
DEFENSE MECHANISM - ALTRUISM dealing with stress/anxiety by helping others
DEFENSE MECHANISM - SUBLIMATION substitute negative impulses into acceptable forms of expression
example
working out hard at the gym
DEFENSE MECHANISM - SUPRESSION voluntary denial of unpleasant thoughts/feelings
DEFENSE MECHANISM - REPRESSION unconscious denial of unpleasant thoughts/feelings
DEFENSE MECHANISM - REGRESSION reverting back to childlike behaviors that are inappropriate for current level of
development
