ATI Mental Health Retake/Remediation 2019-Verified Study Guide

Mental Health Remediation
Discharge plan for alcohol disorder:
Safety is the primary focus of nursing care during acute intoxication or withdrawal.
Direct the client’s focus to the substance abuse problem
Educate client/family about codependent behavior
Educate client/family about addiction and tx goal of abstinence
Hold client firmly to reasonable limits, consistently reinforcing rules, with reasonable consequences of breaking rules
Do not share medications. Hold accountable
Develop motivation and commitment for abstinence
Help develop emergency plan, people to contact
Encourage attendance at group therapy/support group
Alcohol withdrawal: Severe
Hallucinations, diaphoresis, hyperthermia, tachycardia
Withdrawal DELIRIUM is a medical emergency. Death can occur from MI, fat emboli, peripheral vascular collapse, electrolyte imbalance, aspiration pneumonia, or suicide.
Treatment: oWithdrawal: benzos, clonidine (sedative/antihypertensive), phenobarbital, naltrexone
oAbstinence: disulfiram, naltrexone, acamprosate
Depressive Disorders: Priority findings to share with treatment team
****** Monitor both a depressed client and a client who has recently been prescribed an antidepressant medication closely for signs of suicidal ideation. If the client presents with increased energy, monitor closely because it could mean that the client now has the energy to perform the suicide act‼‼
Assess the client’s risk for suicide and implement appropriate safety precautions .
Self-care: Monitor the client’s ability to perform activities of daily living and encourage independence as much as possible.
Communication: Make observations rather than asking direct questions, which can cause anxiety in
the client. For example, the nurse might say, “I noticed that you attended the unit group meeting today,” rather than asking, “Did you enjoy the group meeting
Females are more likely at risk for depression
Priority assessment for a client who has delirium Rapid over a short period of time (hours or days)
S/S: restlessness, anxiety, motor agitation, and fluctuating moods. Personality change is rapid. Provide safe and therapeutic environment: assess for potential injury, wandering. Assign close to nurses’ station. Decrease any stimuli. Well- lit room. Wear alert bracelet. Use restraints as last resort. Assess for injury.
Primary step is determining underlying cause!
Best way to prevent is to minimize risk factors and promote early detection
Use of restraints on a child (chp 12)
8 years and younger: every 4 hrs. Seclusion is every 1 hr
Need doctor’s order (NO PRN)
2 fingers fit in between wrist
Reassess and rewrite rx every 24 hrs.
Assess (safety and physical needs)
Offer food/fluid/toileted/vital signs
Monitor pain
Complete documentation every 15 to 30 mins
Restraints, from the least restrictive to the most restrictive, are:
Mitten restraints that are used to prevent the dislodgment of tubes, lines and catheters
Wrist restraints that are used to prevent the dislodgment of tubes, lines and catheters
A vest restraint that is used to prevent falls as well as disturbed violent behavior
Arm and leg restraints that are used to prevent violent behavior
Leather restraints that are also used to prevent violent behavior
Applying restraints (chp 2)
Obtain order from provider (current and specific)
Plan for one on one observation
Ensure 2 fingers fit between wrist
Document client’s behavior every 15 min while on restrains
Contributing factors to development of conduct disorder oClients who have conduct disorder demonstrate a persistent pattern of behavior that violates the rights of others or rules and norms of society. Categories of conduct disorder include the following: -Aggression to people and animals
-Destruction of property
-Deceitfulness or theft
-Serious violations of rules
Childhood onset develops before the age of 10, with males being more prevalent.