ATI Capstone Mental Health
Mental Status Exam includes:
Level of consciousness
Physical appearance
Behavior
Cognitive and intellectual abilities
The nurse conducts the MSE as part of his or her routine and ongoing assessment of the client.
Changes in Mental Status should be investigated further and the provider notified.
2 types of mental health hospitalizations
Voluntary commitment and involuntary or civil commitment. Involuntary commitment is against
the client's will. Despite that, unless proven otherwise, clients are still considered competent and
have the right to refuse treatment.
Communication tips
If the client is anxious or depressed - use open-ended, supportive statements If the client is
suicidal - use direct, yes or no questions to assess suicide risk If the client is panicked - use
gentle guidance and direction If the client is confused - provide reality orientation If the client
has delusions / hallucinations / paranoia - acknowledge these, but don't reinforce If the client
has obsessive / compulsive behavior - communicate AFTER the compulsive behavior* If the
client has a personality or cognitive disorder - be calm and matter-of-fact
Treatment for mental health illnesses and disorders can include
medications, talk and behavior therapy, and / or brain stimulation. Clients undergoing care for
mental health disorders may feel pressure to deny behavior or issues to appear 'normal'. The
nurse should always carefully assess each individual to ensure optimal response to therapies.
Brain Stimulation Therapy
electroconvulsive therapy or ECT. ECT is generally performed for major depressive disorders,
schizophrenia, or acute manic disorders. Most clients receive therapy three times a week for two
to three weeks. Prior to ECT, carefully screen the client for any home medication use. Lithium,
MAOIs, and all seizure threshold medications should be discontinued two weeks prior to ECT.
After therapy, reorient the client as short-term memory loss is common.
anxiety disorders
,Anxiety disorders are common mental health disorders. Generalized Anxiety Disorder, Panic
Disorder, Phobias, Obsessive Compulsive Disorder, and Posttraumatic stress disorder (PTSD)
are all considered types of anxiety disorders. Assess the client for risk factors, triggers, and
responses.
Depression Symptoms
A classic symptom of depression is change in sleep patterns, indecisiveness, decreased
concentration, or change in body weight. Any client who shows these signs or symptoms should
be asked if they have suicidal ideation. Teach clients to never discontinue antidepressants
suddenly.
Bipolar Disorders
mood disorders with periods of depression and mania. Clients have a high risk for injury during
the manic phase related to decreased sleep, feelings of grandiosity, and impulsivity.
Hospitalization is often required and nurses should provide for client safety.
Types of Abuse
physical, sexual, or emotional. Abuse tends to be cyclic, following a pattern of tension building,
battering, and honeymoon phase. When test questions appear related to abuse, look for the
phase to determine the correct response.
Aggressive or violent patient
setting boundaries and limits on behavior is important. The nurse should maintain a calm
approach and use short, simple sentences.
SSRIs: Selective Serotonin Reuptake Inhibitors
These medications include Citalopram (Celexa), Fluoxetine (Prozac), or Sertraline (Zoloft). The
client should avoid using St. John's Wort with these medications, and should eat a healthy diet
while on these medications.
TCAs: Tricyclic Antidepressants
Amitriptyline (Elavil) is an example. Anticholinergic effects and orthostatic hypotension may
occur.
MAOIs: Monoamine Oxidase Inhibitors
, Phenelzine (Nardil) is an example. Hypertensive crisis may occur with tyramine food ingestion,
so care must be taken to avoid these substances. Educate the client to avoid all medications
until discussed with provider.
Atypical antidepressants
Bupropion (Wellbutrin) is the most common example. Appetite suppression is a common
side-effect. Headache and dry mouth may be severe and client should notify the provider if this
occurs. Atypical antidepressants should not be used with clients with seizure disorders.
Serotonin Norepinephrine Reuptake Inhibitors
Common SNRIs include Venlafaxine (Effexor) and Duloxetine (Cymbalta). Adverse effects may
include nausea, weight gain, and sexual dysfunction.
Antagonists
In order to understand how antagonist drugs work, you need to understand how agonist drugs
produce therapeutic effects. Agonists are simply drugs that allow the body’s neurotransmitters,
hormones, and other regulators to perform the jobs they are supposed to perform. Morphine
sulfate, codeine, and meperidine (Demerol) are opioid agonists that act on the mu receptors to
produce analgesia, respiratory depression, euphoria, and sedation. These drugs also work on
kappa receptors, resulting in pain control, sedation, and decreased GI motility. Antagonists, on
the other hand, are drugs that prevent the body from performing a function that it would normally
perform. To quote William Shakespeare & the US Army, these drug classes allow the body’s
functions “to be or not to be…all that they can be.”
Common use of antagonists
· Treatment of opioids overdose, reversal of effects of opioids, or reversal of respiratory
depression in an infant
· Example: a postoperative client receiving morphine sulfate for pain control experiences
respiratory depression and is treated with naloxone (Narcan)
Nursing interventions for antagonists
Monitor for side/adverse effects
· Tachycardia and tachypnea
· Abstinence syndrome in clients who are physically dependent on opioid agonists
· Monitor for symptoms to include cramping, hypertension, and vomiting
· Administer naloxone by IV, IM, or subcutaneous routes, not orally
· Be prepared to address client's pain because naloxone will immediately stop the analgesia
effect of the opioid the client had taken
Mental Status Exam includes:
Level of consciousness
Physical appearance
Behavior
Cognitive and intellectual abilities
The nurse conducts the MSE as part of his or her routine and ongoing assessment of the client.
Changes in Mental Status should be investigated further and the provider notified.
2 types of mental health hospitalizations
Voluntary commitment and involuntary or civil commitment. Involuntary commitment is against
the client's will. Despite that, unless proven otherwise, clients are still considered competent and
have the right to refuse treatment.
Communication tips
If the client is anxious or depressed - use open-ended, supportive statements If the client is
suicidal - use direct, yes or no questions to assess suicide risk If the client is panicked - use
gentle guidance and direction If the client is confused - provide reality orientation If the client
has delusions / hallucinations / paranoia - acknowledge these, but don't reinforce If the client
has obsessive / compulsive behavior - communicate AFTER the compulsive behavior* If the
client has a personality or cognitive disorder - be calm and matter-of-fact
Treatment for mental health illnesses and disorders can include
medications, talk and behavior therapy, and / or brain stimulation. Clients undergoing care for
mental health disorders may feel pressure to deny behavior or issues to appear 'normal'. The
nurse should always carefully assess each individual to ensure optimal response to therapies.
Brain Stimulation Therapy
electroconvulsive therapy or ECT. ECT is generally performed for major depressive disorders,
schizophrenia, or acute manic disorders. Most clients receive therapy three times a week for two
to three weeks. Prior to ECT, carefully screen the client for any home medication use. Lithium,
MAOIs, and all seizure threshold medications should be discontinued two weeks prior to ECT.
After therapy, reorient the client as short-term memory loss is common.
anxiety disorders
,Anxiety disorders are common mental health disorders. Generalized Anxiety Disorder, Panic
Disorder, Phobias, Obsessive Compulsive Disorder, and Posttraumatic stress disorder (PTSD)
are all considered types of anxiety disorders. Assess the client for risk factors, triggers, and
responses.
Depression Symptoms
A classic symptom of depression is change in sleep patterns, indecisiveness, decreased
concentration, or change in body weight. Any client who shows these signs or symptoms should
be asked if they have suicidal ideation. Teach clients to never discontinue antidepressants
suddenly.
Bipolar Disorders
mood disorders with periods of depression and mania. Clients have a high risk for injury during
the manic phase related to decreased sleep, feelings of grandiosity, and impulsivity.
Hospitalization is often required and nurses should provide for client safety.
Types of Abuse
physical, sexual, or emotional. Abuse tends to be cyclic, following a pattern of tension building,
battering, and honeymoon phase. When test questions appear related to abuse, look for the
phase to determine the correct response.
Aggressive or violent patient
setting boundaries and limits on behavior is important. The nurse should maintain a calm
approach and use short, simple sentences.
SSRIs: Selective Serotonin Reuptake Inhibitors
These medications include Citalopram (Celexa), Fluoxetine (Prozac), or Sertraline (Zoloft). The
client should avoid using St. John's Wort with these medications, and should eat a healthy diet
while on these medications.
TCAs: Tricyclic Antidepressants
Amitriptyline (Elavil) is an example. Anticholinergic effects and orthostatic hypotension may
occur.
MAOIs: Monoamine Oxidase Inhibitors
, Phenelzine (Nardil) is an example. Hypertensive crisis may occur with tyramine food ingestion,
so care must be taken to avoid these substances. Educate the client to avoid all medications
until discussed with provider.
Atypical antidepressants
Bupropion (Wellbutrin) is the most common example. Appetite suppression is a common
side-effect. Headache and dry mouth may be severe and client should notify the provider if this
occurs. Atypical antidepressants should not be used with clients with seizure disorders.
Serotonin Norepinephrine Reuptake Inhibitors
Common SNRIs include Venlafaxine (Effexor) and Duloxetine (Cymbalta). Adverse effects may
include nausea, weight gain, and sexual dysfunction.
Antagonists
In order to understand how antagonist drugs work, you need to understand how agonist drugs
produce therapeutic effects. Agonists are simply drugs that allow the body’s neurotransmitters,
hormones, and other regulators to perform the jobs they are supposed to perform. Morphine
sulfate, codeine, and meperidine (Demerol) are opioid agonists that act on the mu receptors to
produce analgesia, respiratory depression, euphoria, and sedation. These drugs also work on
kappa receptors, resulting in pain control, sedation, and decreased GI motility. Antagonists, on
the other hand, are drugs that prevent the body from performing a function that it would normally
perform. To quote William Shakespeare & the US Army, these drug classes allow the body’s
functions “to be or not to be…all that they can be.”
Common use of antagonists
· Treatment of opioids overdose, reversal of effects of opioids, or reversal of respiratory
depression in an infant
· Example: a postoperative client receiving morphine sulfate for pain control experiences
respiratory depression and is treated with naloxone (Narcan)
Nursing interventions for antagonists
Monitor for side/adverse effects
· Tachycardia and tachypnea
· Abstinence syndrome in clients who are physically dependent on opioid agonists
· Monitor for symptoms to include cramping, hypertension, and vomiting
· Administer naloxone by IV, IM, or subcutaneous routes, not orally
· Be prepared to address client's pain because naloxone will immediately stop the analgesia
effect of the opioid the client had taken
