NUR 251 Mental Health Concept Map
SCORE
Chief Complaint
Patient is a 26 year old Veteran
after hearing gun shots the patient
all of a sudden couldn’t remember
the basic things about hereslef.
Dissociative amnesia has been linked to overwhelming stress, which may be
caused by traumatic events such as war, abuse, accidents or disasters. The
person may have suffered the trauma or just witnessed it. There may be a
genetic (inherited) connection in dissociative amnesia, as close relatives
often have the tendency to develop amnesia.
Main Disease Process
Medical Lab and Radiology Tests
Common Signs and Symptoms
Interventions and Therapies
Inability to remember past events or activities
Inability to learn new information
Confabulation
Disorientation
Psychotherapy
Cognitive Behavior Therapy
Medications used to treat anxiety
Glucose
Mg
Ca+
UA Drug Screen
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Pathophysiology
Dissociative amnesia is a type of amnesia where
you can’t remember important information
about your life including things like your name,
family or friends, and personal history. It can
happen due to intense trauma or stress.
Nursing Actions
Nursing Priorities
Potential Complications
1. sleep disorders
2. Personality Disorder
Prevention
1. Get mental health stable
2.Medications, group
Recognition
1.Patient sleeping not enough
or too much
2.Patient is easily disturbed by
people
1.
Airway protection
1. Have suction available
2.
Stop seizure diaprazole
2. Bs taken
3.
Asses for causes seizure
3. Vitals taken
4.
Access Blood sugar, drug screen, transfer to higher
level of care
Other Concerns and
Collaboration
Suicide attempt
Neurologist consult
4. Turn patient over
5. Call Rapid Response team
6. Remove all other patients from area
Discharge Planning & Education
Encourage patient to continue therapy
Encourage patient to take medications
Contact the HCP if they feel suicidal or depressed
Medication Education
Intervention
1. medication, meditation
2. medications, cognitive
therapy
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NUR 251 Mental Health Concept Map
1.
2.
Medication name, class,
dosage, route, and
reason
Escitalopram
Antidepressant
10mg, 20mg
Anxiety
Sertraline
antidepressant 25 mg,
50mg to 100mg,
liquid or capsule,
depression / anxiety
SCORE
Assessment and Evaluation
Monitor HR and BP
Assess for worsening depression
Monitor labs and ECG
Education
Do not take escitalopram with pimozide
Do not take escitalopram with a
monoamine oxidase (MAO) inhibitor
Signs and symptoms of serotonin
toxicity
3.
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NUR 251 Mental Health Concept Map
SCORE
Time
Critical Thinking Questions
(this section will be completed in post-conference)
1. What priority have you identified today? I would identify my patients thought process and what they can handle on their own.
2. What important assessments do you need to make?
Psychiatric interview. The psychiatric interview must contain a description of the client’s mental status with a thorough
description of behavior, flow of thought and speech, affect, thought processes and mental content, sensorium and intellectual
resources, cognitive status, insight, and judgement.
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NUR 251 Mental Health Concept Map
SCORE
3. What advocacy do you anticipate your client needing? How can you provide that advocacy? I may have a to be an advocate for
my patient about everything it just depends how bad their amnesias are what they can remember and cannot. If dementia is
present, I am there only source.
4. What interventions would benefit your client?
5. How did you prioritize implementation of nursing interventions? Provide a rationale.
6. What important teaching information might this client require related to?
a. Their disease processes? Healing is a process and will not happen overnight. Continue to see therapist until you are
comfortable without
b. Their diet? Continue your diet as is and continue your regular exercise regiment
c. Their medications? Take medications are prescribed. Do not stop talking mediation abruptly.
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NUR 251 Mental Health Concept Map
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7. What are you concerned for about this client? My concerns for this client are their feeling self-worthless and not being
comfortable with themselves. I would be concerned about PTSD occurring in their future.
8. What are expected outcomes for this client and how do your interventions help the client move towards healing?
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