FOCUS REVIEW RN MENTAL HEALTH 2019
NSG 4058
Use of restraints on school-Age child
Limits for seclusion or restraints are based upon the age of the client.
 Age 8 years and younger: 1hr
Caring for a Client who is in restraints
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Assessed for safety and physical needs, and the client’s behavior documented
Offered food and fluid, Toileted, monitored for vital signs, Monitored for pain
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Complete documentation every 15 to 30 min (or according to facility policy) includes a
description of the following:
 Precipitating events and behavior of the client prior to seclusion or restraint
 Alternative actions taken to avoid seclusion or restraint
 The time treatment began
 The client’s current behavior, what foods or fluids were offered and taken, needs
provided for, and vital signs
 Medication administration
 Time released from restraints
Planning care for client who has Schizophrenia
 Promote therapeutic communication to lower anxiety, decrease defensive patterns, and
encourage participation in the milieu.
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Establish a trusting relationship with the client
Ask the client directly about hallucinations.
Do not argue with a client’s delusions.
Assess the client for paranoid delusions, which can increase the risk for violence against
other
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FOCUS REVIEW RN MENTAL HEALTH 2019
Risk factors for child abuse
 The child is under 4 years of age.
 The perpetrator perceives the child as being different (the child is the result of an
unwanted pregnancy, is physically disabled, or has some other trait that makes them
particularly vulnerable)
Evaluating constructive use of defense mechanisms
 Evaluate past coping mechanisms.
 Assists the client to identify adaptive and maladaptive coping mechanisms.
Crisis Management: Priority nursing interventions
Care is directed at the resolution of the immediate problem causing a crisis.
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The initial task of the nurse is to promote a sense of safety for the client and protect the
client by assessing the client’s potential for suicide or homicide.
 Assist with admission to an inpatient facility, as needed for clients who have suicidal or
homicidal thoughts.
 Prioritize interventions to address the client’s physical needs first.
Initial interventions include the following.
 Identifying the current problem and directing interventions for resolution
 Taking an active, directive role with the client.
 Encourage active participation by the client in planning solutions and goal setting.
 Helping the client to set realistic, attainable goals
 Use strategies to decrease anxiety.
 Develop a therapeutic nurse-client relationship.
 Remain with the client., listen, and observe.
 Make eye contact.
 Ask questions related to the client’s feelings.
 Ask questions related to the event.
 Demonstrate genuineness and caring.
 Communicate clearly and, if needed, with clear directives.
 Avoid false reassurance and other nontherapeutic responses.
 Teach relaxation techniques.
 Identify and teach coping skills (assertiveness training and parenting skills).
Planning care for a client who has anorexia nervosa
Persistent energy intake restriction leading to significantly low body weight in context of age,
sex, developmental path, and physical health
● Fear of gaining weight or becoming fat
● Disturbance in self-perceived weight or shape
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FOCUS REVIEW RN MENTAL HEALTH 2019
CHARACTERISTICS
● Clients are preoccupied with food and the rituals of eating, along with a voluntary refusal to
eat.
● This condition occurs most often in female clients from adolescence to young adulthood.
● Onset can be associated with a stressful life event, such as college.
● Compared to clients who have restricting type, those who have binge-eating/purging type
have higher rates of impulsivity and are more likely to abuse drugs and alcohol.
Groups and Family Therapy: Recognizing boundaries
HEALTHY FAMILIES: Boundaries are distinguishable between family roles. Clear
boundaries define roles of each member and are understood by all. Each family member can
function appropriately.
DYSFUNCTIONAL FAMILIES
Enmeshed boundaries: Thoughts, roles, and feelings blend so much that individual roles are
unclear
Rigid boundaries: Rules and roles are completely inflexible. These families tend to have
members that isolate themselves and communication is minimal. Members do not share thoughts
or feelings.
Assisting a client with grieving
Support for the grieving family:
● Suggest that family members plan visits in a manner that promotes client rest.
● Ensure that the family receives appropriate information as the treatment plan changes.
● Provide privacy so family members can communicate and express feelings among themselves.
● Determine family members’ desire to provide physical care. Provide instruction as necessary ●
Educate the family about physical changes during active dying. ● Allow families to express
feelings
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FOCUS REVIEW RN MENTAL HEALTH 2019
Expected findings of posttraumatic stress disorder
Intrusive findings (presence of memories, flashbacks, dreams about the traumatic event)
● Memories of the event recur involuntarily and are distressing to the client
● Flashbacks (dissociative reactions where the client feels the traumatic event is recurring in the
present), such as a military veteran feeling that they are reliving a combat situation after hearing
a harmless loud noise
● Night-time dreams related to the traumatic event
● Avoidance of people, places, events, or situations that bring back reminders of the traumatic
event
● Trying to avoid thinking of the event
Improving Medication Adherence
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The commitment and ability of the client and family to follow a given treatment regimen.
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Commitment to the regimen increases adherence.
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Complicated regimen interferes with adherence.
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Involvement of the client and significant support people in the planning stage increases
adherence.
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Adverse effects of medications diminish adherence.
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Negative coping mechanisms (denial) can cause nonadherence; positive coping
mechanisms can
increase adherence.
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Available resources increase adherence
Neuroleptic Malignant Syndrome
MANIFESTATIONS:
● Sudden high fever
● Blood pressure fluctuations
● Diaphoresis
● Tachycardia
● Muscle rigidity
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● Decreased level of consciousness
● Coma
NURSING ACTIONS
● This life-threatening medical emergency can occur within the first week of treatment or any
time thereafter.
● Stop antipsychotic medication.
● Monitor vital signs.
● Apply cooling blankets.
● Administer antipyretics
● Increase the client’s fluid intake.
● Administer dantrolene or bromocriptine to induce muscle relaxation.
● Administer medication as prescribed to treat arrhythmias.
● Assist with immediate transfer to an ICU.
● Wait 2 weeks before resuming therapy.
Consider switching to an atypical agent
Evaluating Therapeutic Effects of Naltrexone
INTENDED EFFECTS: Naltrexone is a pure opioid antagonist that suppresses the craving and
pleasurable effects of alcohol (also used for opioid withdrawal).
NURSING ACTIONS
● Assess the client’s history to determine whether the client is also dependent on opioids.
Concurrent use increases the risk for opioid toxicity.
● Suggest monthly IM injections of depot naltrexone for clients who have difficulty adhering to
the medication regimen.
CLIENT EDUCATION: Take naltrexone with meals to decrease gastrointestinal distress.
Adverse Effects of Disulfiram
Disulfiram used concurrently with alcohol will cause acetaldehyde syndrome to occur. Effects
include nausea, vomiting, weakness, sweating, palpitations, and hypotension. Acetaldehyde
syndrome can progress to respiratory depression, cardiovascular suppression, seizures, and death.
NURSING ACTIONS: Monitor liver function tests to detect hepatotoxicity.
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FOCUS REVIEW RN MENTAL HEALTH 2019
Intervention for Serotonin Syndrome
Serotonin syndrome can begin 2 to 72hr after the start of treatment, and it can be lethal.
MANIFESTATIONS
● Mental confusion, difficulty concentrating
● Abdominal pain
● Diarrhea
● Agitation
● Fever
● Anxiety
● Hallucinations
● Hyperreflexia, incoordination
● Diaphoresis
● Tremors
NURSING ACTIONS: Start symptomatic treatment (medications to create serotonin receptor
blockade and muscle rigidity, cooling blankets, anticonvulsants, artificial ventilation).
CLIENT EDUCATION: Observe for manifestations. If any occur, withhold medication, and
notify the provider.
Preventing Complication of ECT
The typical course of ECT treatment is two to three times a week for a total of 6 to 12 treatments
for depression.
The provider obtains informed consent. If ECT is involuntary, the provider can obtain consent
from next
of kin or a court order.
Pre-ECT work up can include a chest x-ray, blood work, ECG. Benzodiazepines should be
discontinued as they
will interfere with the seizure process
EDICATION MANAGEMENT
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Thirty minutes prior to the beginning of the procedure, an IM injection of atropine sulfate
or glycopyrrolate is administered to decrease secretions that could cause aspiration and to
counteract any vagal stimulation effects (bradycardia).
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At the time of the procedure, an anesthesia provider administers a short acting anesthetic
(etomidate or propofol) via IV bolus.
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FOCUS REVIEW RN MENTAL HEALTH 2019
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A muscle relaxant (succinylcholine) is then administered to paralyze the client’s muscles
during the seizure activity, which decreases the risk for injury. Succinylcholine paralyzes
the respiratory muscles, so the client requires assistance with breathing and oxygenation.
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Severe hypertension should be controlled because a short period of hypertension occurs
immediately after the ECT procedure.
Any cardiac conditions (dysrhythmias or hypertension) should be monitored and treated
before the procedure.
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The nurse monitors vital signs and mental status before and after ECT procedure
Complications
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Memory loss and Confusion
Reaction to anesthesia
Cardiovascular changes
Headache, muscle soreness, and nausea
Relapse of depression
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