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o Mental Health
NR548 WEEK5-8 MENTAL
HEALTH STUDY GUIDE
Week 5
Carlat ch 21 -A state of well-being in which every individual realizes his or her own potential, can cope with normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his/her community o Mental Status Consciousness -Being aware of one’s own existence, feelings, and thoughts of the environment *most elementary of mental status functions Language -Using the voice to communicate one’s thoughts and feelings; heavy social impact Mood and affect -Mood is more durable, a prolonged display of feelings that color the whole emotional life -Affect is a temporary expression of feelings or state of mind Orientation -Awareness of the objective world in relation to the self -Able to name own person, place, and time Attention -Power of concentration, ability to focus on one specific thing without being distracted by many environmental stimuli Memory -Ability to lay down and store experiences and perceptions for later recall -Recent memory evokes day-to-day events -Remote memory brings up years’ worth of experiences Abstract reasoning -Pondering a deeper meaning beyond the concrete and literal Thought process -The way a person thinks; logical train of thought Thought content -What the person thinks – specific ideas, beliefs, the use of words Perceptions -Awareness of objects through 5 senses o Mental Status Exam (MSE) -Professional jargon belongs in TP and TC Appearance -Provides clues about pt’s mental status/dx -ADLs including dress and grooming are often 1 st^ bxs impacted by MH issues
Behavior and attitude -How does pt behave toward NP? -Consider context of interview – i.e. scheduled or in an ED -Descriptors are similar to affect but emphasis is on relationship toward someone Speech -Important diagnostic indicator Rate/rhythm -Rapid or pressured speech may be d/t mania or anxiety -Slow or normal speech Volume -Speaking loudly may be d/t mania, irritability, anxiety -Low volume may be d/t depression or shyness Latency of response -Pausing to think after being asked a question before responding is normal -Decreased latency (not pausing or responding before question has fully been asked) may be d/t mania -Increased latency (long pause) may be d/t depression -Absence of speech may be seen in dementia -Non-sensical speech may be seen in psychotic disorders General quality -Can you follow what the pt is saying or is it disconnected and confusing?
o Cognitive Assessment -Awareness: alert and oriented, somnolent, drowsy, comatose -Memory: immediate recall, short-term, and long-term; assess with orientation test, 3-object recall, or recall of personal events Attention and concentration -Observe pt’s responses; can pt stay on topic? Can pt focus and respond to questions? -Continuum from attentive and focused to confused and distractible Digit span test -Pt is given 5-7 numbers and asked to repeat them forward and backward **Not endorsed by research studies SSST -Pt is asked to subtract 7 from 100 and continue counting back by sevens until told to stop **Not endorsed by research studies; no differences bt hospitalized psychiatric pts and healthy controls MBT (months backward test) -Pt recites 12 months in reverse -Errors of omission are strongly suggestive of cognitive impairment **Fairly sensitive, most research support Insight -Pt’s awareness of illness or situation -Good, fair/limited, poor -Lack of insight: mania, schizophrenia “Why do you think you’ve been having these problems?” Judgment -Pt’s ability to anticipate the consequences of their bx and safeguard their well-being -Good, fair/limited, poor
- Assess based on material gathered during interview Ex: did pt seek help when feeling depressed? Did pt apply for unemployment benefits when laid off? – good judgment Ex: did pt treat depression with a coke binge? – fun, but poor judgment o Mini-Cog (MMSE) -Used to determine memory deficits and r/o significant cognitive issues -Considerations: age, education level, culture Scoring -Recall score: 1 point for each word correctly recalled without prompt (0-3) -Clock drawing score: 2 points for normal clock or 0 points for abnormal clock *Normal clock shows numbers 1-2 in correct order and direction with one hand pointing to 11 and other pointing to 2 (0-2; pass/fail) -Score of 0-2 higher likelihood of cognitive impairment
- Score of 3-5 lower likelihood of dementia, does not r/o some degree of cognitive impairment
Week 6
Carlat ch 32- 34 o Wrapping Up the Interview – 5-10 minutes Educating Your Patient -Briefly state dx in simple terms -Determine what pt knows about that dx and ask about ideas for tx -Provide info on dx if warranted and wanted Define illness, discuss prevalence and course, causes, and options for tx including meds -Med education: med name/class, sxs targeted, length of tx -Allow for questions -Provide written educational materials -Benefits of education: improves adherence, decreases anxiety, addresses misconceptions about dx/tx Treatment Plan
-Ask pt “How do you hope I can help you?” not “What do you
want/expect?” -Negotiate a plan; pts are more likely to adhere if they agree with plan Ideas: PHP/IOP, respite care, staying with a friend/family, taking days off work, have pt call for daily check ins during crisis period, set up more frequent appts, short course of antianxiety meds -Implement the plan F/u appts – schedule with pt during appt *2-week interval for new meds to assess tolerability, efficacy, and need for adjustment *4-week+ interval for stable pts Med trials – discuss ability to pay and side effects Writing Up the Results -Thoroughness, time efficiency, readability *10-15 minutes to produce, no longer than 2-3 pages typed Components
- Identifying data Includes demographic descriptors of the pt and context of the referral Age, sex, marital status, source of referral, occupation, living situation
- Chief complaint Verbatim sentence of pt’s reason for seeking help
- **Referral source
- HPI** Recent psychiatric sxs; pertinent positives and negatives Includes timeframe of recent onset/exacerbation, sx triggers, recent tx Hx of syndrome begins years before interview Hx of present crisis refers to events of past few weeks
- PPH
Week 7
o Telepsychiatry -APA supports telemedicine as a legitimate component of a MH delivery system when telepsychiatry services benefit the pt, maintain autonomy, confidentiality, and privacy, and when used consistent with APA medical ethics policies and established telepsychiatry laws Benefits Improved access to care Reduced costs Improved efficiency Improved integration of care Decreased ED visits Fewer delays in care Improved continuity of care Reduction of transportation-associated barriers Technology Considerations Best practices: -Use a designated technology platform -Verify confidentiality and security of pt information -Have sufficient bandwidth to provide clear, appropriate video and audio quality -Device compliance with HIPAA and state requirements Legal and Regulatory Considerations Best practices: -Malpractice insurance is required; some policies require additional policies for telehealth -Licensure requirements differ from in-person practice; providers must hold a license in the state where the pt resides -Federal and state prescribing guidelines differ for telepsych; provider must conduct an in-person medical eval at least once every 24 months -Reimbursement varies by state and insurance providers; currently, 48 states provide Medicaid reimbursement for telepsych services Clinical Considerations -Provision of tele services is at discretion of provider, dependent upon pt’s needs, capabilities, preferences, and access to technology Best practices to determine appropriateness: -Cognitive capacity -Pt hx and medical status -Geographic distance to emergency facilities -Pt support system Special Populations Considerations Children and adolescents -Modify care based on developmental status -Include family as appropriate
Forensic and correctional
Week 8
o Legal & Ethical Issues in Mental Health HIPAA -Protects privacy of pt’s identifiable information while facilitating communication among providers and other entities to ensure information is available for tx and other purposes such as insurance benefits ROI -Allows providers to share mental/behavioral health information to enhance tx or ensure health and safety of pt and others Duty to Warn -Exception to requirements for confidentiality -Mandatory for NPs to report when pts may pose a danger to self or others -NPs are mandated reporters in cases of suspected child abuse Informed Consent -Should be signed at the beginning of tx -Respects pt’s autonomy in medical decision-making -Pts have the right to receive info and ask questions about recommended txs so they can make decisions about their care that are consistent with their beliefs, values, and goals of tx Steps to Obtaining Informed Consent 1.Assess pt ability to understand medical information and tx options and to make a voluntary decision 2.Present relevant, accurate information about diagnosis, nature and purpose of tx options, and benefits, risks, and burdens of all tx options, including forgoing tx 3.Document convo and all consent forms Documentation -Tx plans with risks and benefits identified -Reasonable alternatives with risks and benefits identified -Assessment of pt understanding of the discussion *Pt should not be coerced into tx Exceptions -Pt incapacitation (legally authorized decision-makers may be appointed) -Life-threatening emergencies -Voluntary waived consent -Pt unable to make decisions and has no designated decision- maker -Involuntary tx Documentation and Implications for Legal Proceedings -Provides a record of evaluation and tx -Serves as an instrument to communicate with other members of the interdisciplinary team, insurers, and others involved in care Psychotherapy Notes
-Notes recorded in any medium by a health care provider who is a MH professional documenting or analyzing the contents of conversation during a private counseling session or a group, joint, or family counseling session and that are separated from the rest of the pt’s medical record -HIPAA requires pt authorization before disclosure -Exceptions: Mandatory reporting of abuse or duty to warn requirements Pt has waived privilege Legal exception to privilege exists Court order exists requiring provider to turn over pt’s info PMHNP must release pt’s medical record to insurer and to the pt. PMHNP must NOT release psychotherapy notes to the pt or another provider. PMHNP must release medical records to the court with a subpoena with pt authorization. o Special Considerations Cognitive Development -Evolution of thought processes from infancy through lifespan -Cognitive activities: remembering, problem solving, decision making Piaget’s cognitive stages Sensorimotor 0-2 years Cognitive abilities based on reflexes Children master object permanence and causality Preoperational 2-7 years Child can use mental representations, symbolic thought, and language Thinking is egocentric Concrete Operational 7- 11 Child uses logical operations when thinking and solving problems Thinking is concrete Formal Operational 12+ Adolescent can use abstract reasoning in addition to logical operations Can understand theories, hypothesize, and comprehend abstract ideas such as love and justice Psychosocial Development (Erikson) Infancy -Trust vs mistrust (birth – 18 months) -When a child’s basic needs are met, they learn to trust the people around them -Children who develop trust will be better equipped to develop trusting relationships with others
-Autonomy vs shame and doubt (18 months – 2-3 years) -Focus is on child’s sense of self-control -Children begin to move from total dependence on a caregiver towards a sense of personal independence Preschool -Initiative vs guilt (3-5 years) -Children begin to exert control over the environment, making decisions about things that impact their lives -When children have the opportunity to make choices within safe boundaries established by caregivers, they develop a sense of initiative -If activities are too tightly controlled, they may not develop confidence in their ability to impact the environment or may experience guilt School age -Industry vs inferiority (6-11 years) -Child’s focus shifts from family-centered interactions to social interactions -As children develop proficiency in friendships and schoolwork, they begin to experience a sense of competence -If children are not successful in resolving this crisis, they may develop feelings of inadequacy Adolescence -Identity vs role confusion (12-18 years) -Individuals work to develop a sense of ego identify through experimentation with different activities, roles, and behaviors -Successful development results in a strong sense of self that remains throughout lifespan -Unsuccessful development leads to insecurity and confusion Young adulthood -Intimacy vs isolation (19-40) -Focus is on creation of loving, intimate relationships with others -Unsuccessful resolution of this stage may lead to feelings of isolation or loneliness Middle adulthood -Generativity vs stagnation (40-65) -Individuals work to create or invest in things that will outlast them and benefit future generations -If they fail to find a way to contribute to the community or society, a sense of disengagement may develop Maturity -Integrity vs despair (65-death) -Development is focused on reflection over life -Successful resolution of this stage leads to a sense of satisfaction and fulfillment in life -Unsuccessful resolution leads to a sense of regret
Maslow’s Hierarchy of Needs Which theory would the PMHNP most need to consider when conducting a psychiatric interview: A 35-year-old homeless pt is in the ED with SI – hierarchy of needs theory A 14-year-old foster child struggling to develop trusting relationships with foster parents – psychosocial A 4-year-old struggling to understand what she has seen on TV about civil protests – cognitive development Children Informed consent -Children typically cannot give informed consent Exceptions: -States that allow minors to obtain healthcare services without parental consent -Emancipated minors – under 18 and married, serving in military, able to provide financial independence, or mother of a child HIPAA and U -Parents usually have access to child’s medical records Exceptions: -Info is contained in psychotherapy notes -State law allows child to give consent for services and parents aren’t designated as representative -Parent voluntarily agrees that info can be kept confidential -Provider has a reasonable belief that abuse/neglect exist, or parent is a danger to the child -Provider believes it’s not in the child’s best interest to treat the parent as child’s representative Interviewing -Consider child/adolescent’s developmental stage and cognitive abilities -Involve family members -Topics to cover: Interests, school and activities, drug/alcohol use, sexual activity, conduct problems In which of these situations would it be appropriate to share a child or adolescent’s PHI with a parent? A 12-year-old who has designated the parent to be the personal representative in a state allowing adolescents to consent to their treatment – yes
-have no interest in sex/intimacy -are stubborn and inflexible -are “cute” or “childlike”
