W15 - Day 9 & 10

Describe emotion-focused coping

Dealing with the emotional response of the stressor and/or situation in a more indirect manner. It's getting away from the feeling, but not solving it or changing it. Example: keeping yourself busy to take your mind off the issue, distracting yourself. Some forms of this type of coping involves isolation or withdrawal from others, or abusive behaviors like drugs or alcohol.

Problem-based history includes:

Depression Anxiety Altered mental status Abusive behaviors: (common) -alcohol abuse - drug abuse - interpersonal violence

Rapid eye test to detect current drug intoxication

General observation -look for redness of sclera, ptosis, retracted upper lid (white sclera visible above iris, causing blank stare), glaring, excessive tearing of eyes, and swelling of eyelids. Pupil size dilated >6.5 mm or constricted <3 mm Pupil reaction to light slow, sluggish or absent response Nystagmus Hold finger in vertical position and have patient follow it as it moves to the side, in a circle, and up and down. Positive test is failure to hold gaze or jerkiness of eye movements. Convergence Inability to hold the cross eyed position after an examining finger is moved 1 foot away from patient's nose and held there for 5 sec. Corneal reflex Decreased rate of blinking after touching cornea with cotton.

How to assess INTERPERSONAL VIOLENCE

If patient answers YES to previous questions the nurse needs to ask additional questions in private. - Be calm, matter-of-fact and nonjudgemental - listen carefully and let patient define problem - gather descriptions of behavior rather than why it happened - nurse may ask different questions to get more comments from patient. You are asked about violence because so many women are dealing with this in their homes Has your partner destroyed things you care about? Has your partner ever threatened or abused your children? Has your partner ever forced you to do something you did not want to do? Has your partner prevented you from leaving home seeing friends, getting a job, or continue your education. Do you have guns in the home?

Describe abnormal findings identified by a mental health assessment that suggest further assessment is needed.

If they have a negative feeling impacting their everyday life, this needs further screening. If the patient answers YES to any question related to violence or abuse, this needs further screening. If your findings after asking about what happens when you and your partner fight? Are negative, this indicates need to further screen for interpersonal violence. If patient is over the NIAAA recommended limits for alcohol consumption, needs further assessment. If patient tells you about rec drug use this needs further assessment.

How to assess ALCOHOL ABUSE

Likely to deny or minimize their drinking. Many people drink alcohol. Do you sometimes drink beer, wine, or other alcoholic beverages? If yes, how many times in the past year have you had more than 5 a day for men or more than 4 a day for women? In the past 2 months has your drinking repeatedly caused or contributed to: -risk of bodily harm -relationship trouble with family or friends? -role failure -run-ins with the law (Yes to 1 or more equals alcohol abuse) Assess further with tools used such as: AUDIT & CAGE

How to assess DRUG ABUSE

Likely to deny or minimize their use to avoid being judged by others. -Some people use recreational drugs. Have you used drugs in the past? If yes, ask: which of the following: cannabis, cocaine, prescription stimulants, methamphetamine, inhalants, sedatives or sleeping pills, hallucinogens, street opioids and prescription opioids used for nonmedical use. -In the past 3 months how often have you used each of the substance you mentioned? -How often have you had a strong desire to use? -How often has your drug use led to health, social, legal or financial problems? -How often have you failed to do what was normally expected of you because of your use of this (these) drugs -Has friend and or relative or anyone else ever expressed concern from your drug use?

The National Institute on Alcohol Abuse and Alcoholism (NIAAA) recommendations:

Men = less than 5 a day or 15 weekly Women =less than 4 a day or 8 weekly Adults age 65 and older =no more than 1 a day or 7 weekly Pregnant women = no level of alcohol consumption is safe.

Identify common problems that may be found during a mental health assessment.

Mental health problems include: depression, anxiety, and altered mental status. Common problems of abusive behaviors include: alcohol abuse, drug abuse, and interpersonal violence.

Review the neurotransmitters relevant to mental health assessment.

Neurotransmitters play a big role in human emotions and behaviors. - Norepinephrine is associated with decreased in depression. (adrenaline) - Seratonin is associated with decreased in depression. (calming neurot) - Dopamine associated with decreased depression and ADHD, but increased in schizophrenia. (stimulant) - Gamma-amino butyric acid (GABA) associated with decreased anxiety.

Identify screening tools appropriate for a mental health assessment.

a. Holmes Social Readjustment Scale b. AUDIT and CAGE c. Patient Health Questionnaire (PHQ-9) d. Mood Disorder Questionnaire e. Hamilton Anxiety Rating Scale f. SAD PERSONS Suicide Assessment Scale

Anxiety (nonpsychotic discorder)

is a feeling of uneasiness or discomfort from mild to panic. Is the response to no specific source or actual object.

How to assess ALTERED MENTAL STATUS

Orientation -what year is it? -where are you? -what is hers or his name? Memory -ask patient to repeat 3 unrelated objects (cat, apple, cloud. Calculation ability (concentration) -ask about making change from a $5 for example. Communication skills -repetition, reading, writing, copying Judgement and reasoning -what would you do if a car were speeding toward you? Abstract reasoning -What does "a bird in the hand is worth two in the bush" mean to you?

Describe how stress affects overall health.

The body response to stress is similar in everyone (fight flight) but different people may feel it in different ways. Example:headache, heart races, prone to more illness, GI symptoms, mood changes. Over time, continuous strain on your body from routine stress may lead to serious health problems (heart disease, high blood pressure

Define Mental Status

The degree of competence that a person shows in intellectual, emotional (not only intensity, but duration), psychologic (how you think?), and personality (what type of traits were they born with?) functioning.

Levels of anxiety

There are 4 levels: Mild - good level that keeps us going. -Thinks more logically; learning occurs during this state. Moderate -person has more of a narrow field of perception -start to focus more on the specific concerns Severe (can'teach and may need meds) -reduced perception -cognitive processes are limited -getting away from the anxious source Panic (can't teach and needs meds) - complete disruption of perception field -unable to think logically -experience terror

Describe problem-focused coping

This is the effective coping. It involves the cognitive process and are efforts to change the stressor. This is something that we want to promote. Example: taking control of the situation, information seeking, evaluating the pros and cons.

Hamilton Anxiety Rating Scale (HAM-A)

To assess the severity of symptoms of anxiety. There is a list of different phrases that describe certain feelings that people have. Each is rated by the patient by finding the answer that best describes the extent to which he/she has these conditions. The patient selects one of the five responses for each of the 14 questions. For each question, the patient selects a score: 0=not present, 1=mild, 2=moderate, 3=severe, 4=very severe Scoring: Each item is scored on a scale of 0 - 4 with a total score range of 0-56, where <17 indicates mild severity, 18-24 mild to moderate severity, and 25 -30 moderate to severe.

How to assess ANXIETY

-Have you had difficulty concentrating or making decisions? Have you been preoccupied or forgetful Are you able to fall asleep and stay asleep without difficulty? -Have you noticed a change in the amount of energy that you have (fatigue)? Have you been more irritable than usual? Do your muscles seem tense? Do you feel a tightening in your throat? -Have you felt nauseated? Do you feel your heart racing? Have you had to urinate more often than usual? -Have you noticed a change in your feelings? If yes, describe them. That do you think initiated them? How did you handle or cope with them?

AUDIT structured interview (Alcohol use disorders identification test)

-Set up with different questions and the nurse writes down the score per question. Each question is giving a score from 0 to 4 where: 0=never, 1=monthly or less, 2=2-4 times per month 3 or 4 monthly, 3=2-3 times per week monthly 5 or 6 weekly, 4=4 or more per week 7-9 daily Score of greater than 8 (out of 41) suggests problem drinking and indicates need for more in-depth assessment. Cut-off of 10 points is recommended by some to provide greater specificity.

NIAAA recommendation of alcohol consumption limits

12 oz beer or cooler 8.5 oz (8 - 9 oz) of malt liquor 5 oz of table wine 3 - 4oz of fortified wine (sherry or port) 2 - 3oz of cordial, liqueur or aperitif 1.5 oz of brandy 1.5 oz of spirits (gin, vodka, whiskey, etc)

Define Mental Health

A state of well-being in which people realize their own abilities, can cope with normal stresses of life, can work productively, and are able to make contributions to their communities.

Discuss the use of pharmacologic therapies used in the treatment of anxiety.

Anti-anxiety medications Benzodiazepines -Xanax, Ativan, Valium, Klonopin (more recommended) Antihistamine - Benadryl (OTC drug) Common side effects -drowsiness, confusion, lethargic, tolerance, may increase depression, orthostatic hypotension, paradoxical excitement, dry mouth, nausea/vomiting. Anti-anxiety and antidepressants (SSRIx) work together These meds are short acting, immediate effect, tapered off long term use, get up slowly, take with food, and avoid coffee/alcohol.

Discuss the use of pharmacologic therapies used in the treatment of depression .

Antidepressant medications SSRIs: (these are usually prescribed by Primary Care doctors. first) - Prozac, Paxil, Zoloft, Celexa, Lexapro Wellbutrin (contains norepinephrine and dopamine) SNRIs: - Cymbalta, and Effexor Common Side effects -dry mouth, sedation, nausea, insomnia/agitation, headache, weight loss (early), weight gain (later), sexual dysfunction. The key is to teach patients to understand that they will have the side effects for about 1 -2 weeks before they start feeling less depressed.

Define and describe the concepts of coping.

Coping is what we do to try to manage our stress, involves behavior and thinking. They could be either bad or good. It could also be conscious or unconscious. It is based on the individual's perception of the stressor and the availability of resources.

how to assess DEPRESSION

Document the gender and age of patient. - Notice facial expression, eye contact, body language, and tone of voice of the patient. - During past month have you felt down, depressed or hopeless? or had little interest or pleasure in doing things? - Are you able to fall asleep and stay asleep without difficulty? Have you noticed any marked changes in your eating habits? Have you recently gained or lost weight without trying? Have you noticed a lack of energy? - Describe your mood. Do you have crying spells? Is it hard to concentrate? Have you been more irritable? How often have you had those feelings? How long did they last? - Do you have friends whom you can trust and who are available when you need them? - Have you had depressive feelings like this before? What did you do about them? - Have there been times when you wanted to escape? Do you want to hurt yourself? Do you have a plan to end your life? Do you know when or how you will end your life?

Discuss health promotion practices that are pertinent to mental health.

Drug abuse: Primary Prevention Enhance Protective factors: -strong positive bond with family -parental monitoring - clear rules of conduct consistently enforced - parental involvement - success in school - strong bonds with church/school Reduce risk factors - chaotic home (parents with substance abuse or mental illness) - ineffective parenting - lack of mutual attachment - shy or aggressive behavior in class - failure in school - poor social or coping skills - association with deviant peer group - adoption of attitude that approves drug abuse. Goals for HealthyPeople 2020 and USPSTF screening.

The CAGE test for alcohol addiction

Easier one to remember. -Have you ever felt you should CUT down on your drinking? -Have you ever been ANNOYED when people have commented on your drinking? -Have you ever felt GUILTY or badly about your drinking? -Have you ever had an EYE opener first thing in the morning to steady your nerves or get rid of a hangover? Score 1 point for each YES answer. 1 =80% chance addicted 2 = 89% chance addicted 3 = 99% chance addicted 4 = 100% chance addicted

Describe age-related variations that are expected during a mental health assessment.

Infants, children and adolescents - variations include asking about drug and alcohol use of their mother during pregnancy for infants or neonates - children asked about experiences in school. How they like school? and if they get into trouble? Ask about their fears in life and include violence at home questions. - Adolescents are asked about school experiences, drug/alcohol feeling depressed/anxiety. Self-esteem is crucial at this age. Older adults -Depression could be thought of as aging. When report of concentrating or sleeping issues.

What kind of things do you notice while performing a General Health History

Is the patient dressed appropriately for the weather? Does his/her mood seem appropriate? Is the affect (emotional state) appropriate? What is the patient's body posture? Is the patient slumped over and looking at the ground with a sad facial expression or walking tall with a brisk step and a smiling face? What is the patient's tone of voice? Does s/he talk in a monotone or happy, expressive voice? Does patient's conversation flow in a logical or meaningful sequence? ---Data collected as you talk with patient and compared to healthy.

Describe interpersonal violence

It is a crime. It is a human rights violation. It could be verbal, mental or physical abuse.

The mood disorder questionnaire

It is to assess bipolar disorders only. - different detailed questions about mood and feelings about self which the patient needs to answer with a Yes or No. - if patient answers "yes" to 7 or more of the 13 items from #1, and "yes" to #2, and "moderate" to #3, this indicates a positive screen. All 3 need to be there for the positive results.

Define abusive experiences

It may influence a person's mental health. Need to ask for history of alcohol, drug or personal abuse.

Patient Depression Questionnaire PHQ-9

Over the last 2 weeks, how often have you been bothered by any of the following problems? 1. Little interest or pleasure in doing things. 2. Feeling down, depressed, or hopeless. 3. Trouble falling or staying asleep, or sleeping too much. 4. Feeling tired or having little energy. 5. Poor appetite or overeating. 6. Feeling bad about yourself - or that you are a failure or have let yourself or your family down. 7. Trouble concentrating on things, such as reading the newspaper or watching television. 8. Moving or speaking so slowly that other people could have noticed. Or the opposite - being so figety or restless that you have been moving around a lot more than usual. 9. Thoughts that you would be better off dead, or of hurting yourself. Rate each question: 0=not at all, 1=several days, 2=more than half the days, 4=nearly every day Total all the columns and then ask: 10. If you checked off any problems, how difficult have these problems made it for you to do your work, take care of things at home, or get along with other people? Interpretation of total scores: 1-4 = minimal depression 5-9 = mild depression 10-14 = moderate depression 15-19 = moderately severe depression 20-27 = severe depression

What do you assess during a General Heath History?

Present Health Status - Are you having any medical problems? - What medications are you taking? Past Heath History - In the past have you experienced any behaviors that could indicate a mental health problem? If yes, describe your experience. How have you coped in the past with this disorder? Are these coping strategies still working for you? Family History - Do you have any blood relatives who have behaviors that could indicate a mental health problem? If so, can you describe the behavior they experience? - Some people witnessed or experienced violence during their childhood. Did you have any experiences with violence in the home while growing up?

Describe the categories of coping strategies:

Problem-focused coping Emotional-focused coping

Identify common problems and conditions that may be found during a mental health assessment.

Psychotic disorders = major depression, bipolar disorder, schizophrenia. Major Depression -abnormal mood state in which a person has a sense of sadness, hopelessness, helplessness, worthlessness and despair resulting from personal loss or tragedy. Bipolar Disorder - a type of depression with episodes of mania depression or mixed moods. Schizophrenia - group of mental disorders that show sever disturbance of thought and associative looseness, impaired reality testing and limited socialization. Anxiety Disorders -Anxiety=uneasiness or discomfort feelings in varying degrees. -Obsessive-compulsive disorder=anxiety symptoms when not being able to do what they want to do at a specific time frame. Substance abuse disorders - Alcohol withdrawals syndrome=2 phases, alcohol withdrawal and alcohol withdrawal delirium - Drug intoxication= clinical findings of acute drug intoxication. Delirium -is a cognitive disorder characterized by a disturbance of consciousness and a change in cognition that develops rapidly over a short period of time. Dementia - is also a cognitive disorder characterized by memory impairment and one of the following disorders: aphasia, apraxia, agnosia, and disturbance of executive functions.

Holmes Social readjustment rating scale

Purpose: to assess the stress level of a patient. It is a rating scale list of 41 different events which have automatically been given a point value. The patient would answer yes or no for any of the events, and the nurse adds the points from each of the events they have experienced during the past 12 months. Scoring: Below 150 points - The amount of stress that you are experiencing as a result of changes in your life is normal and manageable. There is only a 1in 3 chance that you might develop a serious illness over the next 2 yrs based on stress alone. Consider practicing a daily relaxation technique to reduce your chance of illness even more. 150 to 300 points - The amount of stress that you are experiencing as a result of changes in your life is moderate. Based on stress alone, you have a 50/50 chance of developing a serious illness over the next 2 yrs. You can reduce these odds by practicing stress management and relaxation techniques on a daily basis. Over 300 points - The amount of stress that you are experiencing as a result of changes in your life is high. Based on stress alone, your chances of developing a serious illness during the next 2 yrs approaches 90%, unless you are already practicing good coping skills and regular relaxation techniques. You can reduce the chance of illness by practicing coping strategies and relaxation techniques daily.

Describe procedures/examination techniques appropriate for mental health assessment with expected findings.

Routine Techniques -Clean hands -Observe posture and movements (posture erect and body relaxed) -Observe dress and hygiene (clear and appropriate for the weather) -Notice changes is voice, speech, perspiration muscle tension, tremors. -Measure vital signs: BP, pulse, respiration, and breathing patterns. -Observe eye movements and measure pupil size. What you observe tells you a lot about the patient? Who else is with them in the room?

Personal and Psychosocial History includes:

Self-concept -how have you been feeling about yourself? -Do you consider your present feelings as being a problem in everyday life? -How do you describe yourself to others? -What is your best characteristic? -What do you like about yourself? Interpersonal relationships -how have you been feeling about yourself? -Do you consider your present feelings as being a problem in everyday life? -How do you describe yourself to others? -What is your best characteristic? -What do you like about yourself? Stressors -Have there been any recent changes in your life? -Have these affected your stress level? -What are major stressors in your life? -How do you deal with stress? -Are those methods effective for you? Anger - Have you been feeling angry? -Do you feel angry now? -How do you react when angry? Verbally, physically, or do you keep anger inside? -Can you talk about what causes your anger? -We all fight at home: what happens when you and your partner fight? Alcohol Use -how often do you drink alcohol, including beer, wine or liquor? Recreational Drug Use -Do you ever use recreational drugs? If yes, tell me about your drug use?

Define and describe the concepts of stress.

Stress is about change. It is the response to the stressors which cause the stress. Stress is the brain's response to any demand.

Suicide assessment scale SAD PERSONS

Suicide is a risk factor from depression and this is the way to assess for suicide. S=sex (male) A=age <19 or > 45 (biggest group) D=depression (depressed mood, decrease concentration, sleep, appetite, libido) P=previous suicide attempt or psychiatric care E=excessive alcohol or drug use R=rational thinking loss: psychosis, organic brain disorder S=separated, divorced, or widowed O=organized plan or serious attempt N=no social support S=sickness or chronic disease/pain Scoring: 1-2 low risk, 3-4 moderate, 5-6 high,, 7 or more very high.

Describe additional questions a nurse would ask to identify common problems.

When data from the Present Health Status suggests that further assessment is indicated, nurses ask additional questions to identify common problems.

When to use problem-based history?

When data from the Present Health Status suggests that further assessment is indicated, nurses ask additional questions to identify common problems.