nursing 504 04 review for nclex rn® mental health amp crisis intervention
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Mental Health
Depressive Disorders
KEY FEATURES OF DEPRESSION
Depressed mood
Anhedonia
Appetite disturbance/weight change
Sleep disturbance
Psychomotor disturbance
Fatigue or loss of energy
Worthlessness/guilt
Indecision/poor concentration
Recurrent thoughts of death/suicide
TYPES OF DEPRESSIVE DISORDERS
Major depressive disorder
Disruptive mood dysregulation disorder
Persistent depressive disorder (dysthymia)
Premenstrual dysphoric disorder
,BEHAVIOR SYMPTOMATIC OF DEPRESSION
Objective signs
Alterations in activity
Altered social interactions
Subjective signs
Alterations of mood
Alterations of affect
Alterations of cognition
Alterations of physical nature
Alterations of perception
NURSE–PATIENT INTERVENTIONS
Demonstrate respect and rapport with patient.
Accept patient and focus on strengths.
Develop trust through direct, honest interactions.
Acknowledge emotional pain and offer to help work through pain.
Point out accomplishments and strengths.
Re-program patient’s negative thoughts through cognitive-behavioral therapy.
Reinforce efforts to make decisions that promote health and wellness.
Do not reinforce hallucinations or delusions (point out reality without challenging patient’s
perceptions).
Accept patient’s anger and negativity without reinforcing them.
Spend time with withdrawn patient, according to the patient’s level of comfort.
MILIEU INTERVENTIONS
Opportunity to experience accomplishments and receive positive feedback
Assertiveness training
Help avoid embarrassment
Supportive group activities
Assist with grooming and hygiene
Brief and frequent interpersonal contacts
Assist with nutrition and adequate fluids
Protect from suicidal intent
Prevent constipation
Monitor and promote nighttime sleep
, Discourage daytime sleep
SUICIDAL BEHAVIOR
Suicidal clients characteristically have feelings of worthlessness, guilt, and hopelessness so
overwhelming that they feel unfit to live and unable to go on with life.
The nurse caring for a depressed client must always consider the possibility of suicide.
High-Risk Groups
People with a history of previous suicide attempts
People with a family history of suicide attempts
Those with a history of psychiatric hospitalizations or disorders
Socially isolated individuals
People who abuse drugs or alcohol
Those exposed to violence in the home or social environment
People with access to loaded firearms in the home.
Teenagers, males, and older clients
Disabled or terminally ill adults
Professional persons (e.g., lawyers, dentists, physicians, members of the military)
Clues
Client statements indicating the intent to attempt suicide
Preoccupation with death and dying
Giving away personal, special, and prized possessions
Sudden calmness or improvement in a depressed client
Writing farewell notes
Taking care of unfinished business (e.g., making out or changing a will or taking out or changing
insurance policies)
Loss of interest in usual activities
Canceling social engagements
Poor appetite
Sleep difficulties
Excessive risk-taking
Questions about poisons, guns, or other lethal objects
Increased use of alcohol or drugs
The Plan
, Does the client have a plan?
What is the plan and how lethal is the plan?
Does the client have the means to carry out the plan?
Client History of Suicide Attempts
Is there any history of suicide attempts? What were the outcomes?
Was the client accidentally rescued?
Have past attempts and methods been the same, or have methods increased in their potential
for lethality?
Psychosocial Factors
Is the client alone or alienated from others?
Is the client hostile or depressed?
Is the client having hallucinations?
Is the client using alcohol or drugs?
Has the client sustained any recent losses or physical illness?
Has the client experienced any environmental or lifestyle changes?
Interventions for the Suicidal Client
Ensure a safe environment.
Suicide precautions are implemented when the client is considered suicidal; they include
constant one-on-one monitoring, with the client in view at all times and a distance of one arm's
length between the staff member and the client.
The client's statements, behavior, and mood are documented in his or her record every 15
minutes.
Develop a contract: a written, dated, and signed document specifying alternative behavior
when suicidal thoughts occur.
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