Mental status examination (MSE)
Level of consciousness
o Alert
o Lethargic: able to open eyes and response, and falls asleep readily
o Stuporous: not able to respond verbally and response by painful stimuli (sternum
rubbing)
o Comatose: unconscious and not response to painful stimuli
Decorticate: flexion and internal rotation of upper extremity joints and legs
Decebrate: neck and elbow extension, wrist and finger flexion
Physical appearance
o Assess personal hygiene, grooming, and clothing choice
Behavior
o Mood
o Affect: flat effect or lack of facial expression
Cognitive and intellectual abilities
o Assess orientation to time, person, and place
o Assess client able to calculate
For example: can count backward from 100 in serials of 7
o Assess client able to think abstractly
o Assess client rate and volume of speech
Glasgow coma scale
Highest value 15: indicates that client awake and responding appropriately
Score 7 or less: coma
Milieu therapy:
Ensure safe environment for client
Assist client to participate in appropriate activities
Promotion of self-care activities
Offering assistance with self-care task
Allowing time for client to complete self-care tasks
Cognitive and behavioral therapies
Modeling
Operant conditioning
Systemic desensitization
DSM-5
, Diagnostic criteria for mental disorder
Assist care plan for mental disorder
Indicates expected assessment findings of mental health disorder
Ethical
Beneficence: quality of doing good
Autonomy: make own decisions
Justice: fair and equal treatment for all
Fidelity: loyalty and faithfulness
Veracity: honesty
Types of admission:
Voluntary
Temporary emergency: due to inability to make decisions regarding care
Involuntary: admission is based on client need for psychiatric treatment, risk of harm to self or
others or inability to provide self-care
Long-term involuntary
Seclusion and restraint
In general, provider should prescribe seclusion and or restraint for shortest duration necessary
and only if less restrictive measures are not sufficient. They are for physical protection of client
or protect other client and staff
Less restrictive measures
o Verbal intervention: tell client calm down
o Diversion or redirection
o Provide calm, quiet environment
o Offering PRN medication
Time limits:
o 18 years and older: 4hr
o 9-17 years: 2hr
o 8 years and younger: 1hr
Must reassess client and rewrite prescription every 24hr
Should identify nursing responsibilities
o Assess safety and physical needs, and client behavior document
o Offer food and fluid
o Toileted
o Monitoring vital signs
o Monitor for pain
Complete document every 15-30 minutes including:
o Time treatment began
, o Current behavior, what foods or fluids were offered and taken
o Medication administration
o Time released from restraints
In emergency treatment, nurse must obtain written prescription within specified period of time
(usually 15-30 min)
Tort law
False imprisonment: confining client to specific are such as seclusion room
Assault: threatening
Batter: touching client in harmful
Nonverbal communication:
Appearance
Posture
Gait
Facial expression
Eye contact
Gestures
Personal space
Silence
Purpose of therapeutic communication:
Elicit (explore) and attend to client thoughts, feelings and needs
Express empathy and genuine concerns
Obtain information and give feedback about client condition
Essential components of therapeutic communication
Time:
o allow adequate time to communicate
Attending behaviors or active listening
o Eye contact
o Vocal quality enhance rapport and emphasize
Honesty
Trust
Empathy
Nonjudgment attitude
o Display of acceptance and encourage open, honest communication
Assessment:
Older
Level of consciousness
o Alert
o Lethargic: able to open eyes and response, and falls asleep readily
o Stuporous: not able to respond verbally and response by painful stimuli (sternum
rubbing)
o Comatose: unconscious and not response to painful stimuli
Decorticate: flexion and internal rotation of upper extremity joints and legs
Decebrate: neck and elbow extension, wrist and finger flexion
Physical appearance
o Assess personal hygiene, grooming, and clothing choice
Behavior
o Mood
o Affect: flat effect or lack of facial expression
Cognitive and intellectual abilities
o Assess orientation to time, person, and place
o Assess client able to calculate
For example: can count backward from 100 in serials of 7
o Assess client able to think abstractly
o Assess client rate and volume of speech
Glasgow coma scale
Highest value 15: indicates that client awake and responding appropriately
Score 7 or less: coma
Milieu therapy:
Ensure safe environment for client
Assist client to participate in appropriate activities
Promotion of self-care activities
Offering assistance with self-care task
Allowing time for client to complete self-care tasks
Cognitive and behavioral therapies
Modeling
Operant conditioning
Systemic desensitization
DSM-5
, Diagnostic criteria for mental disorder
Assist care plan for mental disorder
Indicates expected assessment findings of mental health disorder
Ethical
Beneficence: quality of doing good
Autonomy: make own decisions
Justice: fair and equal treatment for all
Fidelity: loyalty and faithfulness
Veracity: honesty
Types of admission:
Voluntary
Temporary emergency: due to inability to make decisions regarding care
Involuntary: admission is based on client need for psychiatric treatment, risk of harm to self or
others or inability to provide self-care
Long-term involuntary
Seclusion and restraint
In general, provider should prescribe seclusion and or restraint for shortest duration necessary
and only if less restrictive measures are not sufficient. They are for physical protection of client
or protect other client and staff
Less restrictive measures
o Verbal intervention: tell client calm down
o Diversion or redirection
o Provide calm, quiet environment
o Offering PRN medication
Time limits:
o 18 years and older: 4hr
o 9-17 years: 2hr
o 8 years and younger: 1hr
Must reassess client and rewrite prescription every 24hr
Should identify nursing responsibilities
o Assess safety and physical needs, and client behavior document
o Offer food and fluid
o Toileted
o Monitoring vital signs
o Monitor for pain
Complete document every 15-30 minutes including:
o Time treatment began
, o Current behavior, what foods or fluids were offered and taken
o Medication administration
o Time released from restraints
In emergency treatment, nurse must obtain written prescription within specified period of time
(usually 15-30 min)
Tort law
False imprisonment: confining client to specific are such as seclusion room
Assault: threatening
Batter: touching client in harmful
Nonverbal communication:
Appearance
Posture
Gait
Facial expression
Eye contact
Gestures
Personal space
Silence
Purpose of therapeutic communication:
Elicit (explore) and attend to client thoughts, feelings and needs
Express empathy and genuine concerns
Obtain information and give feedback about client condition
Essential components of therapeutic communication
Time:
o allow adequate time to communicate
Attending behaviors or active listening
o Eye contact
o Vocal quality enhance rapport and emphasize
Honesty
Trust
Empathy
Nonjudgment attitude
o Display of acceptance and encourage open, honest communication
Assessment:
Older
