Set standards of care for mental American Nurses Association, the American Psychiatric Nurses Associa
health patients the International Society of Psychiatric-Mental Health Nurses
mental health nurses should use the nursing process, as well as a ________
holistic
approach to care for clients in mental health settings.
The various methods used to identify observation, interiewing, physical examination, and collaboration
factors that impact the mental well
being of clients
____ _________ is ongoing and involves monitoring the status of the client w
data collection
each encounter.
*perception of own health, beliefs about illness and wellness
*activity and leisure activities (how the client passes time)
*use and possible abuse of substances
psychosocial history
*stress level and coping abilities (usual coping strategies, support syste
*cultural beliefs and practices
*spiritual beliefs
clients are responsive and able to fully respond by opening their eyes a
alert attending to a normal tone of voice and speech. They answer questions
spontaneously and appropriately.
, ATI Mental Health Test
clients are able to open their eyes and respond but are drowsy and fall
lethargy
asleep readily.
clients need to be lightly shaken to elicit a response, but they may be
obtundation
confused and slow to respond.
clients require painful stimuli (pinching a tendon, rubbing the sternum)
stupor
elicit a brief response. They may not be able to respond verbally.
no response can be achieved from repeated painful stimuli.
coma *abnormal posturing in the client who is comatose
*decorticate or decerebrate rigidity.
examination includes evaluation of client's personal hygien, grooming,
clothing choice. Expected findings with regard to evaluation are that th
physical appearance
client is well-kept, clean, and dressed appropriately for the given
environment.
examination includes observation of voluntary and involuntary body
movements, and eye contact.
behavior *mood-provides information about the emotion that the client is feeling
*affect-an objective expression of mood, such as a flat affect or a lack o
facial expression.