NR 607- Final Exam
Inpatient treatment primary goal *** Crisis stabilization
define seclusion *** involuntary confinement of an individual alone in a room or area from which the
individual is prevented from leaving
use of seclusion *** -Imminent risk of harm to themselves/others
-Laws differ state to state
-Only to ensure the immediate physical safety of pt and others
-Never as means of discipline, coercion, or for staff convenience
Evaluating a clients capacity for decision making *** -Assess for communication barriers: language,
hearing or vision impairments, dysarthria
-Evaluate for reversible causes of incapacity: infection, medications or other substances, acute
neurologic and psychiatric disorders
-Identify values and cultural influences that may impact client decision making
-Ask questions: determine the pt's ability to understand the treatment and how treatment applies to
their situation.
-Identify a surrogate if needed: healthcare advance directive, medical power of attorney, spouse, adult
children, other close relatives
-Document
involuntary civil commitment *** -legal intervention directed by a judge to order a person w serious
symptoms to either remain in psych hospital/ attend supervised outpt tx.
-May be initiated by family member/mental health professional/ law enforcement
-The person in question may have the right to appear at their hearing w counsel and present evidence to
dispute the case
,-The max length of inpatient commitment varies by state.
-Outpatient commitment/assisted outpatient treatment (AOT)= may consist of supported housing,
intensive case management, meds, and frequent therapy
--Tx may last 6- 12 mo
use of restraints-seclusion criteria *** -Only to ensure the immediate physical safety of pt and others
-No evidence that restraints decrease risk of falls
-Last resort
-Never as means of discipline, coercion, or for staff convenience
-Face to face eval and written order required, eval must be completed within 1 hr of application of
restraint/seclusion
--not allowed PRN
--must reevaluate q24h
risk factors of suicide *** -History of substance abuse
-Physical disability/illness
-Losing a friend or family member to suicide
-Ongoing exposure to bullying behavior
mental health condition
-Recent death of a family member/close friend
-Access to harmful means
-Relationship problems
-Previous suicide attempts
physical risk assessment *** -quick visual exam to evaluate
--skin color, sweating, pupil size, level of consciousness, or obvious injuries to ensure adequate airway,
breathing, and circulation.
, -Vital signs may be obtained if the pt permits; if not, continue assessment w/o getting vs.
define psychiatric emergency *** -involve acute disturbances in thought, mood, behavior /social
interactions that negatively impact a pt's abil to function in their environment and require immediate
intervention to keep the pt/others from harm
--a state of crisis that has overwhelmed their coping mechanisms
psychiatric emergencies occur when *** -a danger to self
-a danger to others
-unable to meet their own basic needs for food/clothing/shelter d/t a psychological impairment
common psych emergencies *** suicidality, acute psychosis, agitation and aggression, mania,
substance-related concerns, decompensation r/t personality d/o, severe anxiety, and med-related
emergencies
early signs of aggressive behavior *** threatening comments, clenched fists, shifts in body position
towards a fighting stance, loud vocalizations, agitated movements / striking inanimate objects
interventions for aggressive behavior *** When aggression is unavoidable- prioritize security, sedation,
and supervision
AEIO risk assessment categories *** Agitation/Arousal: sit still? pacing? demonstrating aggressive
behaviors?
Environment: Is the pt in a safe location? Id potential exits, equipment in the room, and the distance of
the room from the rest of the unit.
Intent: pt have thoughts of harming themselves or others? pt having psychotic experiences that may
cause them to harm themselves/others?
Objects: pt have access to firearms, blades, medications, lighters, or clothing items that could be used to
harm themselves/others?
Inpatient treatment primary goal *** Crisis stabilization
define seclusion *** involuntary confinement of an individual alone in a room or area from which the
individual is prevented from leaving
use of seclusion *** -Imminent risk of harm to themselves/others
-Laws differ state to state
-Only to ensure the immediate physical safety of pt and others
-Never as means of discipline, coercion, or for staff convenience
Evaluating a clients capacity for decision making *** -Assess for communication barriers: language,
hearing or vision impairments, dysarthria
-Evaluate for reversible causes of incapacity: infection, medications or other substances, acute
neurologic and psychiatric disorders
-Identify values and cultural influences that may impact client decision making
-Ask questions: determine the pt's ability to understand the treatment and how treatment applies to
their situation.
-Identify a surrogate if needed: healthcare advance directive, medical power of attorney, spouse, adult
children, other close relatives
-Document
involuntary civil commitment *** -legal intervention directed by a judge to order a person w serious
symptoms to either remain in psych hospital/ attend supervised outpt tx.
-May be initiated by family member/mental health professional/ law enforcement
-The person in question may have the right to appear at their hearing w counsel and present evidence to
dispute the case
,-The max length of inpatient commitment varies by state.
-Outpatient commitment/assisted outpatient treatment (AOT)= may consist of supported housing,
intensive case management, meds, and frequent therapy
--Tx may last 6- 12 mo
use of restraints-seclusion criteria *** -Only to ensure the immediate physical safety of pt and others
-No evidence that restraints decrease risk of falls
-Last resort
-Never as means of discipline, coercion, or for staff convenience
-Face to face eval and written order required, eval must be completed within 1 hr of application of
restraint/seclusion
--not allowed PRN
--must reevaluate q24h
risk factors of suicide *** -History of substance abuse
-Physical disability/illness
-Losing a friend or family member to suicide
-Ongoing exposure to bullying behavior
mental health condition
-Recent death of a family member/close friend
-Access to harmful means
-Relationship problems
-Previous suicide attempts
physical risk assessment *** -quick visual exam to evaluate
--skin color, sweating, pupil size, level of consciousness, or obvious injuries to ensure adequate airway,
breathing, and circulation.
, -Vital signs may be obtained if the pt permits; if not, continue assessment w/o getting vs.
define psychiatric emergency *** -involve acute disturbances in thought, mood, behavior /social
interactions that negatively impact a pt's abil to function in their environment and require immediate
intervention to keep the pt/others from harm
--a state of crisis that has overwhelmed their coping mechanisms
psychiatric emergencies occur when *** -a danger to self
-a danger to others
-unable to meet their own basic needs for food/clothing/shelter d/t a psychological impairment
common psych emergencies *** suicidality, acute psychosis, agitation and aggression, mania,
substance-related concerns, decompensation r/t personality d/o, severe anxiety, and med-related
emergencies
early signs of aggressive behavior *** threatening comments, clenched fists, shifts in body position
towards a fighting stance, loud vocalizations, agitated movements / striking inanimate objects
interventions for aggressive behavior *** When aggression is unavoidable- prioritize security, sedation,
and supervision
AEIO risk assessment categories *** Agitation/Arousal: sit still? pacing? demonstrating aggressive
behaviors?
Environment: Is the pt in a safe location? Id potential exits, equipment in the room, and the distance of
the room from the rest of the unit.
Intent: pt have thoughts of harming themselves or others? pt having psychotic experiences that may
cause them to harm themselves/others?
Objects: pt have access to firearms, blades, medications, lighters, or clothing items that could be used to
harm themselves/others?
