Chapter 9—Mental Health and Violence Assessment

Chapter 9—Mental Health and Violence Assessment

Definition of Mental Health
The World Health Organization (WHO) states “There is no health without mental health it [is a] state of well-being in which the individual realizes his or her own abilities, can cope with the normal stresses of life, can work productively and fruitfully, and is able to make a contribution to his or her community mental health is the foundation for wellbeing and effective functioning for an individual and for a community ” (WHO, 2013b)

Introduction Common mental health disorders Depression Schizophrenia
Substance abuse Mental health nursing assessment Screening for preexisting, current conditions All age groups Violence assessment Many forms; unique risk factors, characteristics

Role of the Nurse in Mental Health and Violence Screening
Mental health assessment Considering patient’s culture Based on Patient observation; patient responses Integral to any full medical or nursing examination Must be inferred from answers to questions, behaviors Cannot be directly observed Assessment for violence is also included.

Violence, Including Types
Approximately 1/3 of women are victims worldwide. Often goes unreported Family violence Victim is biologically related to offender. Or was related via marriage, adoption, or legal guardianship Descriptive terms used Domestic violence; intimate partner violence (IPV); male violence against women

Types of Human Violence
Types of family violence Child maltreatment Trauma symptoms: anxiety; depression; anger; aggression Sibling violence: rivalry, roughhousing, competition Intimate partner violence (IPV) Perpetrators most often male Behavior involving Threatened/actual violence and/or coercive tactics Psychological/emotional abuse

Types of Human Violence—(cont.)
Types of family violence—(cont.) Intimate partner violence (IPV)—(cont.) IPV among immigrants, refugees Culturally acceptable Victims may have limited options of escape, barriers. IPV in pregnancy Elder abuse: abuse; neglect; financial exploitation; abandonment Risk factors: dependency; cognitive decline; caregiver mental/physical health strain; finances

Violence against adults with disabilities Includes harmful acts of commission (abuse) or omission (neglect) Intentional/unintentional abuse/neglect: physical; sexual; psychological; financial More likely Severe and long-term abuse; victims of multiple violent episodes Abused by many perpetrators Sexual assault exceptionally high in women with developmental disabilities

Youth and school violence Punking: verbal and physical violence; humiliation and shaming; in public or with an audience Bullying: verbal violence, especially in middle and high school girls Sexual violence Forced sex in dating, marital relationships Gang rape; sexual harassment; molestation Inappropriate touching; sex with a patient Forced prostitution; forced exposure to sexually explicit behavior

Hate crimes: Perpetrator chooses a victim because of a characteristic, provides evidence that hate motivated the crime. Race; ethnicity; gender; sexuality; religion Human trafficking: recruitment, transportation, transfer, harboring, or receipt of people through threats, force, coercion, or deception for indentured servitude Major perpetrators: Commercial sex trade businesses Sexual exploitation; forced marriage Cheap domestic/commercial labor Domestic servitude; Sweatshop factories; migrant agricultural work

War-related violence War-related fighting can involve Witnessing killing; intentionally killing, injuring other humans; being intentionally injured, potentially killed Victims Veterans; families of veterans; refugees Higher rates of IPV perpetration: veterans with posttraumatic stress disorder (PTSD) R/T combat exposure

Interviewing Patients About Violence
Patient interviews Paramount: patient physical, emotional safety Completed in private: Patient data is confidential. Listen > talk: (80% patient, 20% nurse) Generalized strategies Preface sensitive questions to prepare patient. Assess daily routine. Include questions about adverse childhood, family events.

Urgent Assessment Questions: violence; harm to self/others
Situation includes risk for injury due to Psychotic states; depression Dementia; delirium Ask safety questions first; leave presenting situation for last. Prevents forgetting to ask about safety Allows more time to focus on presenting situation

Subjective Data Includes Statements to the nurse
Overheard patient reporting (to someone else) Family and friends’ report, validation of patient’s data Ask open-ended questions. Assessment: art as well as a science Assimilating verbal and nonverbal data Establish rapport first. Be aware: patient divergent strategies; motivation for tactics

Assessment of Risk Factors
Assessment of violence and mental health conditions; exacerbating factors Unchangeable factors: family history, age, gender Environmental (changeable) factors: support systems, housing, health care accessibility, literacy Metabolic issues/associated physiological processes: Parkinson disease; cancer; HIV/AIDS; other chronic conditions Identification of risks identifies health promotion teaching topics

Assessment of Risk Factors—(cont.)
History and risk factors Personal history Psychosocial history Support network Substance use Spirituality Medications Family history

Risk Reduction and Health Promotion
Important patient education topics Alterations in interest: life, motivation, energy, sleep, appetite; sexual behavior Current stressors, coping; violence Physical, sexual abuse; altered mood, affect Pervasive worry, anxiety; substance use Changes: behavior; self-harm; suicidal thoughts Memory, concentration, problem-solving abilities Healthy People health promotion goals

Common Symptoms Common symptoms of altered mental health
Suicide ideation Homicide ideation and aggressive behavior Altered mood and affect Auditory hallucinations Visual hallucinations Other hallucinations

Lifespan Considerations: Older Adults
Additional assessment questions Risk factors to assess Female gender African American or Hispanic Social isolation; widowed, divorced, separated Lower socioeconomic status; insomnia Comorbid medical conditions; uncontrolled pain Functional or cognitive impairment Geriatric Depression Scale

Cultural Considerations
Using an interpreter for a patient with a mental health condition Interpreter signs HIPAA/confidentiality statement. Discusses communication with appropriate health care providers only Interpreter cannot divulge any information to patient’s family members or friends. Post interview: May ask interpreter regarding cultural beliefs which could impact treatment Include interpreter’s name in nursing documentation.

Question Is the following statement true or false?
Common symptoms of altered mental health include auditory and visual hallucinations.

Answer Rationale: Altered sensory perceptions include auditory, visual, tactile, and olfactory hallucinations.

Objective Data Collection
Comprehensive mental health assessment Objective data: observing patient, patient’s behavior Physical presentation: may be first indication Toxicity; underlying medical problem; psychosis Data organization (ABCT) plus MMSE Appearance: overall; posture; movement; hygiene, grooming; dress Behavior: level of consciousness; eye contact, facial expressions; speech

Objective Data Collection—(cont.)
Data organization (ABCT) plus MMSE—(cont.) Cognitive function: orientation; attention span; memory; judgment Thought processes and perceptions: MMSE/Mini-Cog. Mini-mental state examination (MMSE)

Comprehensive Violence Assessment
Part of mental health assessment: objective findings R/T patients victimized by violence Nonverbal behaviors: possible abuse, neglect “Red flags” Violence victims’ symptoms common during assessment Easily triggered: anxiety, panic episodes Isolation, social withdrawal; difficulty focusing Numbing/shutting down feelings Spacing out; forgetfulness Documentation

Mandated Reporting When child, elder, vulnerable-adult abuse or neglect is disclosed, assessed, or suspected Mandated reporters: nurses, health care professionals, etc. Must call protective services hotline Mandated reporter is protected by the state: if report is made in good faith, without malice Document call to protective services hotline. Reason for call; time of call; full name of who took call; response of call taker

Assessment of Dementia, Confusion, Delirium, and Depression
Dementia: More common in older adults Gradual process (months to years) Delirium: Generally has an underlying medical cause Resolves after treatment of cause Dementia clues Seems disoriented; “poor historian” Defers to family member to answer questions Repeatedly, unintentionally, fails to follow instructions Word usage difficulties Difficulty following conversations

Critical Thinking Nursing diagnoses Patient outcomes (partial list)
Patient: does not harm self; demonstrates appropriate social interaction; identifies person strengths Nursing interventions (partial list) Assess for risk of harm to self, others. Provide safe environment by removing items which may cause harm. Identify support systems, involve them in care.

NCLEX-Style Review Questions
A nurse is working with a new patient, doing a standard assessment. To establish rapport, the nurse would use which of the following statements? “These are questions that I ask all my patients.” “Don't worry because we are used to working with patients.” “We're here because we want to help people with mental health issues.” “These questions are silly, but I have to ask them.”

Rationale: This response makes the encounter seem normal. The other answers discount the importance of the questions, which might prevent the patient from further disclosing information.

The patient's family should not be present during the interview with the patient about violence because the patient may feel uncomfortable speaking openly with a relative present, especially if that person is contributing to the patient's stress. the patient may not answer questions related to the family member that could be perceived as insensitive or inappropriate. the family member may be ashamed or embarrassed by the patient's actions or statements and try to withhold or change the facts. the family member may be a perpetrator of abusive behavior, and thus the patient may be hesitant to honestly answer questions

Rationale: There are many reasons why a family member should not be used to interpret. Doing so changes the role and dynamics for the family member acting as the interpreter. In addition, if any legal matter arises, the interview would be considered unacceptable documentation. Family members can be used to help with educating patients, encouraging them to take medications, and encouraging them to perform self-care.

“Do you have any thoughts of wanting to kill or harm yourself?” is a common question to assess for suicidal ideation because it is blunt and patients cannot refuse to answer. will cover both suicidal and parasuicidal thoughts. is subtle, and patients will not know how to answer. will encourage patients who perform self-harm to stop cutting

Rationale: This broad and general question opens the conversation, normalizes the response, and covers a wide variety of ways that patients may hurt themselves.

When charting general appearance and behavior, documentation may include which of the following? “Alert and oriented × 3.” “Thought logical.” “Judgment intact.” “Clothes disheveled.”

Rationale: General appearance and behavior represent objective data that the nurse obtains through observation. The other assessments are subjective data based on conversation with the patient.

Abnormal movements from side effects of medications might be described as voluntary deliberate uncoordinated smooth and even

Rationale: Normal movements are voluntary, deliberate, coordinated, smooth, and even. Uncoordinated movements include akathisia, akinesia, dystonia, parkinsonism, tardive dyskinesia, and neuroleptic malignant syndrome.

Normal speech is audible. This is a normal finding describing which quality of speech? Fluency Quality Loudness Articulation

Rationale: The term “audible” refers to loudness. Characteristics of speech to evaluate include rate, rhythm, loudness, fluency, quantity, articulation, content, and pattern.

A 90-year-old patient has a drooped body position, appears sad, and says that she has seasonal affective disorder. What tool would the nurse use to assess her? MMSE CAGE HOPE Geriatric Depression Scale

Rationale: The Geriatric Depression Scale would be used because the patient is a 90-year-old with a type of depression. MMSE is used to test cognition, CAGE is the alcohol assessment tool, and HOPE is the tool for spirituality.

Which of the following represents the nurse's documentation of a patient with normal mood? Pleasant or appropriate to situation Grandiose or strongly confident Fearful but mildly humble and meek Sad and tearful during conversation

Rationale: Abnormal moods are described as sad, tearful, depressed, angry, anxious, grandiose, and fearful.

Patients may laugh spontaneously, provide inappropriate responses, ask the nurse personal questions, or insult the nurse. These are examples of perseveration auditory hallucinations divergent tactics altered mood

Rationale: The patient is attending to the nurse in this situation but is using distracting tactics, so the nurse does not get answers to the questions asked. The patient who perseverates repeats content. Those with auditory hallucinations may respond to voices rather than the nurse. Patients with an altered mood will be more focused on their mood than the nurse.

The MMSE is used to assess for severity of alterations in orientation, registration, attention and calculation, recall, and language. For which of the following patients would the MMSE be most appropriate? Women during the postpartum period Adolescents struggling with sexual orientation Various cultural groups not tested by other tools Adults, to assess for cognitive impairment

Rationale: The MMSE was developed for adults and, although tested in groups with a cultural focus, is valid for all adults.

When questioning a patient about violence, it is best to ask to get the police involved to collect evidence. have the perpetrator present to assess his or her behaviors. move from general to specific questions. ask the patient what he or she did to provoke the violence

Rationale: Open-ended questions are more general and give the patient the freedom to disclose the situation without bias or judgment. It is best to start with open- ended questions and to follow-up with clarifying questions as the patient appears more comfortable and rapport is established.

Signs and symptoms that are “red flags” for violence include which of the following? Stating that everything is just fine. Displaying mood and behavior changes. Expressing sadness over loss. Wanting to have family involved

Rationale: Red flags include new onset or changes in behaviors, withdrawal, depression, agitation, hyperarousal, new displays of anger, noncompliance, sexualized behavior, bowel or bladder problems, sleep problems, and unexplained and/or curious injuries.

Chapter 9—Mental Health and Violence Assessment

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