Mental Health Notes Exam 1 - Mental Health Exam 1 Class 1...

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Mental Health - Exam 1 Class 1 – Health, Wellness, and Illness Chapter 1: Basic mental health nursing concepts Nurses should use various methods to assess clients. These methods include observation, interviewing, physical examination, and collaboration. Assessment Each encounter with a client involves an ongoing assessment. Psychosocial History Perception of own health, beliefs about illness and wellness Activity/leisure activities, how the client passes time Use of substances/substance use disorder Stress level and coping abilities – usual coping strategies, support systems Cultural beliefs and practices Spiritual beliefs The Mental Status Examination (MSE) Level of consciousness is described using the following terms, and observed behavior included in documentation. o Alert – The client is responsive and able to fully respond by opening her eyes and attending to a normal tone of voice and speech. She answers questions spontaneously and appropriately. o Lethargy – The client is able to open her eyes and respond but is drowsy and falls asleep readily. o Stupor – The client requires vigorous or painful stimuli (pinching a tendon or rubbing the sternum) to elicit a brief response. She may not be able to respond verbally. o Coma No response can be achieved from repeated painful stimuli. Abnormal posturing in the client who is comatose o Decorticate rigidity – flexion and internal rotation of upper-extremity joints and legs o Decerebrate rigidity – neck and elbow extension, wrist and finger flexion Physical appearance - Examination includes assessment of personal hygiene, grooming, and clothing choice. Expected findings with regard to this assessment are that the client is well-kept, clean, and dressed appropriately for the given environment. Behavior - Examination includes assessment of voluntary and involuntary body movements, and eye contact. o Mood – A client’s mood provides information about the emotion that she is feeling. o Affect – A client’s affect is an objective expression of mood, such as a flat affect or a lack of facial expression. Cognitive and intellectual abilities o Assess the client’s orientation to time, person, and place. o Assess the client’s memory, both recent and remote. Immediate – Ask the client to repeat a series of numbers or a list of objects. Recent – Ask the client to recall recent events, such as visitors from the current day, or the purpose of the current mental health appointment or admission.
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Remote – Ask the client to state a fact from his past that is verifiable, such as his birth date or his mother’s maiden name. o Assess the client’s level of knowledge. For example, ask him what he knows about his current illness or hospitalization.
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