NRSG210 Mental Health Nursing

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NRSG210 Mental Health Nursing

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NRSG210 Mental Health Nursing

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Course Code: NRSG210
University: Australian Catholic University

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Discuss About The Snapshot If The Psychological Functioning?

The purpose of Mental State Examination (MSE) is to assess the mental state and behaviour of an individual at the time of interview. The goal of MSE is the identification of signs and symptoms pertaining to mental illness for providing proper assistance to the client and addressing of related risks. This exam provides a systematic appraisal and reflects the snapshot if the psychological functioning of a person at a given time period. This examination provides a comprehensive and cross-sectional mental state description of a patient that help a nurse or clinician for making accurate diagnosis for the planning of coherent treatment (Dong, et al., 2012).

MSE can be performed in a wide range of settings like psychiatric or in an outpatient hospital settings by registered nurses and clinicians. For the registered nurses, MSE is useful as it provides a comprehensive assessment of mental state that include medical, psychiatric, medication and personal history of the client. It is useful for the screening of cognitive impairment and its monitoring over time. This examination help the RNs to assess the general behaviour and appearance, attentiveness, level of consciousness, mood and effect, language, memory, alertness, abstract reasoning and constructional ability which are most clinically relevant for measuring cognitive abilities (Wajman, Oliveira, Schultz, Marin, & Bertolucci, 2014).
Various domains are considered in a typical MSE for the systematic appraisal. Appearance: The appearance of the client is important that provide significant clues about their quality of life, lifestyle, self-care and ability to perform the activities of daily living. For example, if a client is well dressed, it demonstrates the clothing and grooming of that person. If a person’s clothing is clean, it demonstrates that if the person performs hygiene on a daily basis or not. These distinctive features are being demonstrated in the appearance domain (Saliba, et al., 2012).
Behaviour: This important domain demonstrates the behaviour of a person during the examination. Non-verbal communication is given special attention and monitoring is done during the interview that reveals the attitude, emotional state of a person. For example, if the level of arousal is high during the examination, it demonstrates agitation or aggressive behaviour of a person. The body language, facial expression, posture, eye contact is noticed during MSE. For example, if a person lacks eye contact during MSE, it demonstrates the poor response of the client to assessment and level of social engagement and rapport with the registered nurse or the clinician. Movement and psychomotor activity is also noticed under this domain such as the client is hypoactive or hyperactive. It also depicts the unusual features like tremors, repetitive, slowed or involuntary movements (Taylor, 2013).
Speech and content of speech: This domain is helpful in revealing the presentation of a person’s feature during MSE. The behaviour and content of the speech is important as it help to depict the language of a person. For example, if the person demonstrates unusual speech that might be associated with anxiety and mood problems, organic pathology or schizophrenia. It is observed that if the person’s speech rate is rapid, pressured or reduced. The volume (normal, loud, soft) is observed along with tonality (tremulous, monotonous), quantity (voluble, minimal) and ease of conversation. This is useful in the demonstration of these possible descriptors along with rhythm and fluency whether the content of speech is clear, slurry, hesitant, aphasic or with good articulation (Altmann, Tian, Henderson, & Greicius, 2013).
Mood and Affect: This domain is useful in the conceptualization of the relationship between the economics affect and mood. Affect is defined as the immediate emotional expressions. On the other hand, mood explains the emotional experience of a person over a prolonged time. For example, affect demonstrates the stability of a person like labile or stable. Happiness is demonstrated by mood whether it is elevated, ecstatic, depressed or lowered. Affect also explains the appropriateness (inappropriate, appropriate or incongruous) and range (flat, restricted, expansive or blunted) of a person. Irritability is defined by mood whether the person is calm, explosive or irritable by nature (Cumming, Churilov, Lindén, & Bernhardt, 2013).
Thought: The thinking of a person is evaluated based on nature or thought content and process or thought form. Content explains various aspects of thought process like delusions, ideas, suicidal or self-harm ideation, obsessions or anxiety. For example, if a person demonstrates false beliefs that are rigidly this is not consistent to one’s background depicts delusions. Unreasonable beliefs demonstrate overvalued ideas, preoccupations and depressive thoughts. Repetitive thoughts about a catastrophic or feared outcome greatly illustrate obsessions of a person. Anxiety is explained by phobias where a person demonstrates heightened anxiety (Forbes & Watt, 2015).
Thought process shows coherence and formation of thoughts which is greatly reflected in the speech of a person and expression of ideas. Various thought levels are explained through process like if a person demonstrates derailment or loose associations, it reflects irrelevant thinking. Tangential thinking or flight of ideas reflects frequent changing of topic, excessive vagueness depicts circumstantial thinking, use of nonsense words and thought clocking or racing is reflected in halted or pressured speech.
Perception: This domain is important for the detection of serious mental health issues like psychosis, mood disorders or severe anxiety. It is also helpful in the measurement of perceptual disturbances marked by frightening or disturbing perceptions. For example, if a person demonstrates derealisation or depersonalization, it depicts dissociative symptoms. For example, if a person who thinks that surrounding things are not real and unusual characterizes illusions. Hallucinations can be auditory, visual where a person’s sensory modalities are affected and the nurse or clinician note the degree of distress or fear that are associated with hallucinations (Douglas & Robertson, 2013).
Cognition: This domain refers to the current capacity of processing of information, as it is sensitive in case of mental health problems. If a person is unaware of the time, place or person and incapable of providing his or her personal details, it depicts disorientation to reality. It also measures the level of consciousness whether the person is drowsy, alert, stuporous or intoxicated. It also measures the memory functioning, arithmetic and literacy skills, concentration and attention and the ability of a person to deal with the abstract concepts (Sattler, Toro, Schönknecht, & Schröder, 2012).
Insight: It is the triaging of the psychiatric presentations and the person’s ability to take decisions about their safety. For example, it is the acknowledgement of a person regarding possible mental health problem in understanding the possible treatment and its compliance. It also measures the ability for the identification of potentially pathological episodes like suicidal impulses or hallucinations (Douglas & Robertson, 2013).
Anxiety and depression: Severe anxiety disorders are characterized by the depressive symptoms and may produce suicidal ideation, agitation and risk for suicide. In anxiety and depression, speech domain in MSE is affected where the person demonstrates unusual speech that might be pressured, rapid or with reduced tempo. Thoughts are also affected due to anxiety where there might be heightened anxiety or the person witness specific phobia. Most importantly, if a person is suffering from anxiety and depression, there is disturbance in perceptions like dissociative symptoms, illusions, hallucinations. Based on the physical appearance, anxious patients would exhibit restlessness, sweaty palms and distractibility. The mood might be normal or depressive. The behaviour and psychomotor activity is also affected in anxiety and depression where the patient exhibit hyperactivity and agitation (Cosco, Doyle, Ward, & McGee, 2012).
Behaviour and mood is significant part of anxiety because it changes these parameters in some way or the other. Certain neurotransmitters acting as chemical messengers help in the communication of different nervous system parts and regulate behaviour and mood. In anxiety, GABA (gamma-aminobutyric acid) does not work properly that leads to overreaction or vigilance feeling and hyperactive behaviour. Anxiety affects cognition like thoughts about fear of dying and suspected dangers where amygdala and hippocampus are affected. There is high response to the emotional stimuli that increases anxiety. Unusual speech is recognized in anxiety as muscle tension makes the movement harder resulting in abnormal speech. During anxiety or depression, speech is controlled by the person rather than by subconscious mind resulting in abnormal speech (Ng, Y., & Schlaghecken, 2012).
Psychotic disorders: There is abnormal thinking, delusions, hallucinations and perceptions that are affected by psychotic disorders. The person experience visual or auditory hallucinations that are considered perpetual disturbance. The thinking ability is disrupted in psychotic disorders and delusions occur where the person has false beliefs that are rigidly held. Dopamine plays an important role in the internal representations, pays attention to the emotional stimulus, and prepares response. However, in psychosis, dopamine is released at random events leading to abnormal information gating and aberrant salient experiences. Hallucinations are accompanied by auditory or visual hallucinations where there is activation of modality-specific activation in the cerebral areas that are involved in sensory processing. However, there is alteration in the Amygdala-Visceral and Hippocampus leading to over activation and inability to distinguish between external stimulation and self-generated thoughts including activation of Wernicke’s area and there are auditory hallucinations (vices heard outside in contrast to the inside due to plenum temporal activation). The primary neurotransmitter, dopamine has increased pharmacological effect that gives rise to hallucinations or psychotic delusions. There is delusional thinking and the person is unable to find or connect the meaningful relationships between ideas or unrelated stimuli. This is the reason the person have an impaired relationship with the reality (Fusar-Poli, et al., 2012).
Patient-centred care: It is a holistic approach where the specific needs of the individual are respected. There is personalization of the care and support given to the client where the mental health nurses understand the culture and specific needs are included in the mental health services given to the client. Their choices and needs are supported in a way that fits the way they want to live. In mental health nursing, personalized service is given that reflect listening and improved understanding and empathy towards the people who experiences mental health issues as witnessed in MSE (Barry & Edgman-Levitan, 2012).
Cultural appropriateness: In mental health nursing, cultural appropriateness is important as the healthcare providers have to be aware of the mental health issues faced by diverse groups. The mental health services need to be culturally competent so that they are able to support the clients with mental health issues from culturally diverse groups. The healthcare services should be adequate to identify and understand the language and cultural differences of the mental health patients and in reducing the stigmatization associated with them (Doyle, 2012).
The multidisciplinary team: In mental health nursing, the multidisciplinary system comprises of the psychiatrists, clinical nurses, specialists, psychologists, mental health nurses, occupational therapists, medical secretaries and sometimes advocacy and care workers. These professionals have different expertise combined with skills who work together in tackling challenging and complex mental health issues of the patients. This team work in collaboration and in a dedicated manner contributing to the assessment, diagnosis, treatment and management of the mental health issue towards holistic patient-centred care (Chalmers, Harrison, Mollison, Molloy, & Gray, 2012).
Psychotropic medications: The psychiatric drugs are used for the alteration of chemical levels in the brain that has an impact on the behaviour and mood. This medication provides safety and stability from paralysing anxiety, however, the benefit differs from patient to patient. Some important drugs include Xanax, Zoloft, Celexa, Prozac, Ativan, Desyrel and Lexapro help to improve the symptoms of depression, neuroticism and extroversion by calming them down in few weeks of use (Rössler, 2012).
Depression Anxiety Stress Scale (DASS): A self-reported instrument of 42 items measures the negative states of emotion of anxiety, depression and stress or tension. DASS scores interpret that the values for depression, anxiety and stress should be low as much as possible and has certain cut-off values. The scores range from zero depicting that the items are not applicable for them to three that means items can be applied to them for most of the time. The main purpose of this tool is to identify and isolate the emotional disturbance aspects. For example, in psychiatric or outpatient settings, the registered nurses or clinicians do the assessment for the degree of severity for the core anxiety, depression or stress symptoms. It is helpful for the registered nurses as it helps to measure the negative and emotional states of anxiety, depression and stress. The scores obtained by the patient would help the nurses to calculate by summing the scores for the relevant parameters. In the clinical setting, the nurses clarify the emotional disturbance that is the broad task for the clinical assessment. DASS scale help them to make decisions based on the score profiles in the clinical examination. Moreover, the clinicians would be able to determine the suicidal ideation and risk for any kind of suicide in the disturbed persons. The aim of this scale is to define and explore the core symptoms of anxiety, depression and stress and meeting of the rigorous standards of psychiatric adequacy and development of discrimination between the anxiety depression scales to the maximum. The experienced registered nurse or clinician interpret and decide based on DASS result score for the anxiety, depression or stress (Happell, Scott, Platania?Phung, & Nankivell, 2012).
There are specific ethical and legal considerations while conducting the mental health assessment by the mental health professionals. Firstly, informed consent need to be obtained from the patient or client before the commencement of mental health assessment as it the ethical duty for the evaluation of the mental health issues. In this, the patient or client need to know about the nature and purpose of the mental health assessment along with potential disclosures and confidentiality associated with the assessment. In cases where there is third party involvement that also need to be informed to the patient. Confidentiality is the second ethical consideration where the mental health professional conducting the assessment are obliged to maintain a certain degree of confidentiality, respect for patient privacy in the legal and ethical context. There should not be any kind of disclosure of the patient information associated with the particular evaluation.  Apart from these ethical and legal considerations, the mental health professions have the obligation to disclose only relevant information with the healthcare team for the diagnosis, treatment and management of the mental health conditions. The legal considerations involve no breaching of these ethical considerations while conducting the mental health assessment. It is the duty of the mental health professionals to maintain the confidentiality of the evaluee by writing an authorization before the release of information and taking into consideration to release only the authorized information (Oei, Sawang, Goh, & Mukhtar, 2013).
Patient-centred care: It is a measure where the metal healthcare professionals work for the development and implementation of actionable plan for the patient who scored concerning scores in DASS scale. The care is developed to fulfil the goals of personal recovery that scored significant marks in DASS scale. There is designing of care plans that promote oriented care and recovery that minimizes symptoms of anxiety, depression or stress (Manary, Boulding, Staelin, & Glickman, 2013).
Cultural appropriateness: Many patients come from culturally and diverse backgrounds suffering from mental health issues and stigmatization. There is lack of healthcare services in the mainstream that works to meet the cultural needs of these diverse patients and acts as a barrier. Therefore, there is need for mental health givers to be knowledgeable and culturally competent in providing culturally appropriate care for the ethnic patients as cultural factors greatly influence the therapeutic process (Purnell, 2014).
The multidisciplinary team: MDT comprising of psychiatrist, clinical and mental health nurses, therapists and psychologists work in inter-professional collaboration in the diagnosis, treatment and in providing metal health services that improve the state of anxiety, depression or stress and enhance services rendered by the institutions. Among the MDT, nurses are the most important professionals who help to establish contact and interpersonal relationship with the patient and provide highest quality of care (Videbeck, 2013).
Psychotropic medications: For the patients who scored significant marks in DASS scale, it is important to give class of psychotropic medications like antidepressants and anti-anxiety agents. These treatments are safer as antidepressants help with phobias, panic attacks, suicidal thoughts, sleeping thoughts and eating disorders. Tranquilizers or anti-anxiety drugs are used to treat anxiety that interfere the patients in their daily life. Benzodiazepines are also used acting as tranquilizers (Wexler, 2013).
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Chalmers, A., Harrison, S., Mollison, K., Molloy, N., & Gray, K. (2012). Establishing sensory-based approaches in mental health inpatient care: a multidisciplinary approach. Australasian Psychiatry, 35-39. doi: 10.1177/1039856211430146 Retreived from: https://sci-hub.io/10.1177/1039856211430146
Cosco, T. D., Doyle, F., Ward, M., & McGee, H. (2012). Latent structure of the Hospital Anxiety And Depression Scale: a 10-year systematic review. . Journal of psychosomatic research,, 180-184. doi:10.1016/j.jpsychores.2011.06.008. Retreived from: https://sci-hub.io/10.1016/j.jpsychores.2011.06.008
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Dong, Y., Lee, W. Y., Basri, N. A., Collinson, S. L., Merchant, R. A., Venketasubramanian, N., & Chen, C. L. (2012). The Montreal Cognitive Assessment is superior to the Mini–Mental State Examination in detecting patients at higher risk of dementia. International Psychogeriatrics, 1749-1755. doi:10.1017/S1041610212001068. retreived from: https://sci-hub.io/10.1017/s1041610212001068
Douglas, G. N., & Robertson, C. (2013). Macleod’s Clinical Examination E-Book. Elsevier Health Sciences.
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Forbes, H., & Watt, E. (2015). Jarvis’s Physical Examination and Health management. Elsevier Health Sciences.
Fusar-Poli, P., Bonoldi, I., Yung, A. R., Borgwardt, S., Kempton, M. J., Valmaggia, L., & … McGuire, P. (2012). Predicting psychosis: meta-analysis of transition outcomes in individuals at high clinical risk. Archives of general psychiatry, 220-229. doi: 10.1001/archgenpsychiatry.2011.1472 Retrieved from: https://jamanetwork.com/journals/jamapsychiatry/fullarticle/1107408
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Sattler, C., Toro, P., Schönknecht, P., & Schröder, J. (2012). Cognitive activity, education and socioeconomic status as preventive factors for mild cognitive impairment and Alzheimer’s disease. . Psychiatry research, 90-95. doi: https://doi.org/10.1016/j.psychres.2011.11.012 Retrieved from: https://sci-hub.io/10.1016/j.psychres.2011.11.012
Taylor, M. A. (2013). The neuropsychiatric mental status examination. Elsevier.
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Wajman, J. R., Oliveira, F. F., Schultz, R. R., Marin, S. D., & Bertolucci, P. H. (2014). Educational bias in the assessment of severe dementia: Brazilian cutoffs for severe Mini-Mental State Examination. Arquivos de neuro-psiquiatria, 273-277.  doi: https://dx.doi.org/10.1590/0004-282X20140002  Retrieved from: https://www.scielo.br/scielo.php?pid=S0004282X2014000400273&script=sci_arttext&tlng=pt
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