Chapter 1 and 2 ATI

Time limit for seclusion/restraint for people 8 years and younger

1 hour

In the event of an emergency where a nurse needs to restrain the client, they must obtain a written prescription from the provider within

15 to 30 minutes of placing the restraints. Restraints must be removed once the client is exhibiting behavior that is safer and quieter.

Time limit for seclusion/restraint for people 9 to 17 years

2 hours

Time limit for seclusion/restraint for people 18 and older

4 hours

What is the time limit of involuntary admission?

60 days at which time a psychiatric and legal review of admission is required.

Mental Status Examination (MSE)

A formal assessment of cognitive functions such as intelligence, thought processes, and capacity for insight.

Terms used to describe level of consciousness

Alert: responsive, able to respond appropriately Lethargic: pt can open eyes and respond but is drowsy and can readily fall asleep stuporous: requires vigorous & painful stimuli to get a brief response.

Components of the psychosocial history

Clients perception of own health/beliefs about illness & wellness. clients activities and leisures clients history of substance abuse Assessing clients stress level, coping abilities, usual coping strategies and support system. Cultural beliefs and practices Spiritual and religious beliefs

Standardized assessment tools for geri-psych

Geriatric depression scale, Michigan Alcoholism screening test, and MMSE

Assessment

Detailed medication history is obtained. Following the interview, summarize and ask the client for feedback. e Each encounter with the client involves an ONGOING ASSESSMENT.

Justice

fair and equal treatment of all patients

HEADSSS

Standardized assessment tool for children and adolescents and assesses: - home environment (relationships w/people they live with) - education/employment - activities - substance abuse - sexuality - suicide/depression - safety

Involuntary admission

The client enters the mental health facility against their will for an indefinite period of time. The admission is based on the client's need for psychiatric treatment, the risk of harm to self or others, or the inability to provide self-care.

Assessment of cognitive & intellectual abilities

This is asssement of: clients orientation to time, person and place Recent memory- ask client to recall recent events like why they are in the hospital remote- asking patient to recall mother's maiden name immediate memory- ask patient to repeat a series of numbers or list of objects

Behavior assessment

assessment of voluntary/involuntary body movements, eye contact, mood and affect.

Certication of requirement of involuntary admission

can be done by physicians (the number of depends on the state) or by a family member, legal guardian, primary care provider or mental health provider

Temporary emergeny admission

client is admitted for emergency mental health care due to the inability to make decisions regarding care. The length of the temporary admission varies on the client and state laws but usually doesn't exceed 15 days.

When a client is restrained/secluded, the nurse must complete documentation...

every 15 to 30 minutes and include a description of - precipitating events/behaviors prior to being restrained/secluded - alternative actions taken to avoid seclusion/restraint - the time treatment began - the client's current behavior, what foods or fluids were offered AND taken, needs provided for and vitals. - medication administration - time released from restraints.

Veracity

honesty when dealing with a client

When can a health care provider break confidentiality?

in the case where they have a duty to warn and protect third parties, and the reporting of child and vulnerable adult abuse.

Informal admission

least restrictive, client doesn't pose a threat to self or others and is free to leave the hospital whenever they want even AMA.

Fidelity

loyalty and faithfulness to the client and one's duty

If the need for the client to be restrained/secluded continues past the approved time limit then the provider...

must reassess the client and rewrite the prescription that specifies the type of restraint, every 24 hours or frequency of time according to facility policy.

Confidentiality

the nurse can only share info about the client to people not involved in their care if the client provides consent

In the event of a violent episode with a mentally ill client, the nurse should document

the situation clearly and objectively: the client's behavior, the staff response, and the time the nurse notified the provider.

Criteria for involuntary admission

poses a threat to self or others presence of mental illness demonstrates severe disability or inability to meet basic needs including food, clothing and shelter Requires treatment but unable to seek it voluntarily related to the impact of the mental illness.

The following steps must occur in order to use seclusion or restraint

provider must prescribe the restraints/seclusion in writing. Time limits are based on the age of the client.

Beneficence

quality of doing good, could be described as charity. Doing something for someone without gain.

Long term involuntary admission

similar to temporary commitment but must be imposed by the court. Time of commitment varies and is usually 60 to 180 days. Sometimes there is no set release date.

Mini-Mental State Examination (MMSE)

standardarized screening tool used to objectively assess a clients cognitive status by evaluating: A/O Attention span and ability to calculate Registration and recalling of objects Language, ability to read, write, follow commands and name objects

Voluntary admission

the client or client's guardian chooses admission to a mental health facility in order to obtain treatment. Client is considered competent and HAS THE RIGHT TO REFUSE MEDS AND TREATMENT. Before release, a client can be evaluated and if deemed necessary, the care provider can initiate an involuntary admission

Autonomy

the client's right to make their own decisions (informed decision without the nurse giving advice)

Less restrictive measures that are done before using seclusion or restraints

verbal interventions (encouraging client to calm down) diversion or redirection providing a calm and quiet environment offering a PRN medication

Timeout

voluntarily requested by the patient in the case that the environment is too stimulated/disturbing. The difference between a timeout and seclusion is that a timeout is requested by the client.

Are clients under involuntary admission still considered competent?

yes, and they can still refuse medication and treatment. If the client has been judged imcompetent and has a temporary or permament guardian, then that person can be appointment and sign informed consent for the patient and is expected to consider what the client would want if they were still competent.