NRSG263 Mental Health Exam Revision

TERMINOLOGY
Mental Disorder – A significant disturbance in a person’s perceptual interpretation, behaviours,
cognition, memory, or emotional regulation that reflects a dysfunction in the psychological or developmental
process and functioning. E.g. Dementia, brain injury, eating disorders, or personality disorder.
Mental Illness – Condition diagnosed by a medical professional according to standardised criteria,
affecting how a person thinks, feels, and interacts with others.
Psychosocial – Having to do with mental, emotional, social, and spiritual effects of a mental illness.
Consumer – A person who has a lived experience of a mental health condition.
The Stepped-Care Approach – Least restrictive to most intensive. Consumer matched to the intervention
level suitable to their needs. Aims to keep people out of acute care and get them back into their community.
Collaborative Care – Team-based care including a nurse, social worker, psychologist, and psychiatrist.
All members of the care team work together with the consumer to holistically achieve goals.
Positive Symptoms – Best described as ‘excess’ of, or additional symptoms/afflictions/experiences.
Positive does not mean ‘good’ – not a literal interpretation. Respond well to unconventional/atypical
antipsychotics.
Negative Symptoms – Best described as a ‘removal’ or withdrawal of normal everyday functioning.
Negative symptoms are the relative absence of normal patterns of behaviour involving emotional
responsiveness, spontaneous speech, and volition. Respond poorly to typical/conventional antipsychotics.

FACTORS CONTRIBUTING TO MENTAL HEALTH CONDITIONS

Adverse Experiences – Sexual, physical, or emotional abuse. Violence in the home, running away from
home. Domestic and family violence. Childhood institutionalisation, serious neglect. Bullying, poverty,
trauma. Rejection, humiliation, embarrassment, making offense. Exposure to actual or threatened death,
serious injury, or sexual violence. Emotional burdens.
Social Determinants (Social, Environmental, Economic, Genetic) – Trauma events in a specific
environment. Poverty, violence, forced migration, stigma. Insecure living conditions, homelessness.
Education opportunities, employment. Financial stressors, parenting/family issues and situation. Critical
events (E.g. loss and grief). Substance abuse.
Vulnerable Populations – Low socioeconomic status. People with chronic health conditions.
Infants/children exposed to maltreatment/neglect. Adolescents exposed to substance use early. Minority
groups. Indigenous populations. Older people. LGBTIQ+. People experiencing natural
disasters/war/conflict. Immigrants and refugees. Prisoners.
Stigma – Public Stigma. Self-stigma. Impacts of stigma like avoiding help, social or physical isolation,
diminished self-esteem, decline in mental illness symptoms, reduced recovery, reduced empowerment.
Stigma contains 3 elements: Problems with knowledge (ignorance), Problems of attitudes (prejudice),
Problems of behaviour (discrimination).
Discrimination – Age, gender, race, sexuality, socioeconomic status, Indigenous,

VICTORIA MENTAL HEALTH ACT

• Reduce inequities in access and delivery of mental health services.
• Provide comprehensive, safe, and quality mental health services.
• Respond to the broad range of circumstances that influence mental health in various ages of people.
• Aim to provide the same treatment and support irrespective of voluntary or compulsory treatment.
• Protect and promote human rights and dignity of people with mental illness, by providing them with
assessment and treatment in the least restrictive way.
• Recognize, promote, and actively support the role of families, carers, and supporters.
• Accessible and safe care for Aboriginal people to support connection to culture, family, and country.
• Supported and empowered decision making.

RESTRICTIVE INTERVENTIONS
Should only be used in accordance with approved protocols and best practice by properly trained
professional staff in an appropriate environment.”
Seclusion – When a person is placed alone in a room and cannot leave by themselves, they cannot leave
on their own accord.
Restraint – Physical restraint used to stop their hands or body moving freely. Sedation is debated.
MENTAL STATE EXAMINATION
The MSE is the cornerstone of mental health assessment acting as a baseline of their mental functioning.
Aim – To evaluate a patient's mental state with questions to identify problems and develop appropriate
treatment. Involves clinical judgement, critical thinking, and ongoing assessment.
Sections – Appearance, Behaviour, Mood (subjective), Affect (objective), Speech, Thoughts (process,
form, content), Perception, Cognition, Insight, Judgement.
Result – To determine a holistic view of the patient and their individual circumstances and needs. Analyse
collected information and recognise patterns to gain insight into a consumers mental health status.

Completing the MSE may present challenges as the consumer may be:
• Difficult to engage with
• Highly distressed, tearful (E.g. Upset suicide attempt was thwarted)
• Latency in responses
• Self-depreciating
• Increasing use of alcohol and drugs
• Perceptually nil abnormalities detected outwardly.
• Dishevelled (consider ADLs)
• High risk of self-harm, suicide
• Difficulty finding periods to interrupt conversation or being able to ask questions.
• Issues with following consumers train of thought
• Irritability
• Poor concentration and distractibility
• Possible provocativeness or over-familiarity
• Increases in self-esteem/grandiosity presenting as arrogance.
• Inability to sit still and tolerate lengthy interview.

RISK ASSESSMENT
Analysis of risk and protective factors of behaviours, potentially harmful. It identifies risk factors in
reference to health history, ideation and current mental state, intent, planning, and formulation.

RISK FACTORS FOR MENTAL HEALTH CONDITIONS

Mental Health History – Previous attempts (static risk factor). Diagnosed mental illness, especially
Major Depressive Disorder. History of past trauma or violence (static risk factor). Alcohol or drug abuse.
Psychotic phenomenon (dynamic risk factor). Poor impulse control and judgement (dynamic risk factor).
Marked decline in functioning (dynamic risk factors). Voicing feelings of hopelessness, worthlessness, guilt
(dynamic risk factor). Negative coping mechanisms. Non-compliance with treatment (dynamic risk factor).
Strong adherence to treatment, always thinking about it. Delusions. Hallucinations (Auditory, visual,
gustatory, olfactory, tactile). Concurrent illness and medical comorbidities.
Physical Factors – Heavy use of daily alcohol/drug consumption. Sleep deficits. Nutrition deficits.
Absconding. Disorganised speech patterns. Catatonic or rigid behaviour. Echolalia. Made up words/phrases
that only have meaning to the speaker.
Genetic Factors – Family history, especially of completed suicide (static risk factor). Previous history of
mental illness. Gender (static risk factor). Sexuality. Race and culture, especially prevalent for Aboriginal
people. Age, especially young people or older males. Immunocompromised (mental health worsens it).
Socioeconomic Deprivation – Social isolation. Rural and remote isolation. Homelessness (dynamic risk
factor). Poverty. Unemployment and earnings (dynamic risk factor). Education and training attainment.
Health literacy. Psychological distress. Access to health services. Financial situation. Criminal history.
Stressful life events (static risk factor). Poor support systems after the event(s).

PROTECTIVE FACTORS FOR MENTAL HEALTH CONDITIONS

Social Support – Family, friends, carers. Stable relationships.
Faith – Religion. Faith and spiritual beliefs. Community involvement. Cultural and spiritual traditions.
Personal – Resilience. Emotion regulation. Healthy coping mechanisms. Anxiety or depression well
managed. Positive self-esteem.
Medical – Linkages with health services such as GPs, community programs, psychologist or therapists,
nurses. Strength-based approach within mental health services.
TRIGGERS FOR MENTAL HEALTH DISORDERS
Physical – Environment, similar place, hospital, enclosed spaces, home. Noise, loud environments,
certain sounds (loud). Physical discomfort. Pain. Medical or nursing procedure needing to be done.
Excessive heat or cold. Large social situations. Being around or seeing certain people as a trigger.
Mental – Change, rigid routines. Memories of past anxiety triggered. Personal fears, of the unknown, of
something physical. Loss or grief.

PHYSICAL HEALTH INTERRELATIONS WITH MENTAL HEALTH

Comorbidities = Metabolic Syndrome. Interrelations between physical and mental health increases risk of:
• Obesity
• Impaired blood glucose levels (T2DM)
• Heart disease
• Stroke and AMI
• Hypertension
• Weakened immune system.
• Decreased diet and nutritional needs.
• Hormonal imbalances
• Cancer

NURSING CONSIDERATIONS IN MENTAL HEALTH

• Recognise relationships between mental and physical health.
• Gain insight into the mental health condition, and personalised symptoms, of their patients.
• Identify physical health issues commonly experienced by people with mental illness.
• Develop an understanding of the experience of people with mental health issues.
• Understand the mental health nurse's role in assessing mental health, as well as physical (vitals).
• Understanding and addressing the issue is crucial in providing comprehensive care.
• Support provided by recognizing the signs, risks, and collaborating with HCP.
• Promoting Patient Safety
• Establishing Therapeutic Relationships, communication, and providing trauma-informed care

SIGNS AND SYMPTOMS OF MENTAL HEALTH CONDITIONS /DISORDERS

Mental – Depressed mood most of the day, nearly every day. Diminished interest and pleasure in daily
activities. Feelings of worthlessness or guilt. Recurrent thoughts of death or suicidal ideation. Excessive
anxiety and worry. Personal fears, of losing control or “going crazy”. Sleep disturbances. Recurrent and
involuntary distressing memories or dreams of trauma events/flashbacks. Dissociative reactions. Actively
avoiding distressing memories, thoughts, or feelings. Self-destructive behaviour, hypervigilance,
exaggerated startle, decreased concentration. Attempts to ignore, suppress, neutralise such thoughts.
Recurrent and persistent thoughts, urges or images that cause marked anxiety (OCD). Repetitive behaviours
or mental acts. Excessive involvement in risky activities. Feeling hopeless. Chronic feelings of emptiness.
Inappropriate, intense anger or difficulty controlling anger. Hostility. Blame projection.
Physical – Weight loss or gain without dieting. Insomnia or hypersomnia. Psychomotor agitation or
retardation. Irritability. Agitation. Fatigue or energy loss. Diminished ability to think or concentrate. Muscle
tension, chest pain. Distress impacting occupational and social functioning. Sweating. Heart palpitations.
Trembling, shaking, choking. Paraesthesia's (numbness or tingling). Nausea or abdominal distress. Changes
in vital signs. Response is out of proportion to actual danger imposed. Restlessness. Social isolation or
withdrawal, detachment from others. Large unsanctioned weight loss (or failure of expected weight gain for
children). Passive or social withdrawal. Poor maintenance of ADL’s. Non-suicidal self-injurious behaviour.

TREATMENTS FOR MENTAL HEALTH DISORDERS

Pharmacological – Medications. Combined antipsychotic (risperidone) and psychotherapy.
Medical – Early intervention. MSE. Monitoring vital signs. De-escalation. Graded (gradual) Exposure
therapy. Combination of pharmacological and non-pharmacological interventions. Increased observation.
Panic and acute intervention. Muscle relaxation. Cognitive behaviour therapy. Electroconvulsive therapy.
Psychotherapies – Behavioural strategies. Stress/anxiety reducing practices. Cognitive strategies. Coping
mechanisms. Mindfulness and meditative therapies. Social support. Guided imagery. Metacognitive training.
Acceptance (of control) & Commitment Therapy.
Resilience – Resilience group programs. Relaxation techniques. Diversional therapy. Developing coping
strategies. Lifestyle changes. Complementary/alternative approaches.
NURSING CHALLENGES IN MANAGING MENTAL HEALTH DISORDERS
Stigma, Shame/embarrassment = nil hospitalisation, Risk of suicide and non-suicidal self-injury, bullying,
perceived poor behaviour, and lack of support. Poor communication, strained relationships, and conflict.

TRAUMA INFORMED CARE AND PRACTICE

A strength-based approach responsive to the impact of trauma. Focused on safety, trustworthiness, choice,
collaboration, and empowerment. It is based on the understanding that:
• A number of people living with mental health conditions have experienced trauma.
• Trauma may be a factor for people in distress.
• Trauma may be a lifelong impact for the person’s emotions and relationships with others.

RECOVERY-ORIENTED PRACTICE
The dominant model for patient care in mental health services. It encompasses principles of self-
determination and individualised care to emphasise hope, goal-setting and self- management.
1. Support personal recovery and promote wellbeing.
2. Deliver services informed by evidence and the social models of health.
3. Build trusting relationships.
4. Use a person-centred approach to better develop client support plans.
5. Ensure care is sensitive to the needs of families and carers.

DISORDERS
Somatic Symptom Disorder – Formerly known as hypochondria. Form of anxiety.
Factitious Disorder – A mental disorder in which a person repeatedly and deliberately acts as if they
have a physical or mental illness when they are not really sick. Factitious disorder can be imposed on
another person or themselves. Formerly Munchausen Syndrome.
Serotonin Syndrome – Dangerous condition associated with excess amount of serotonin caused by a
higher dose or mixing medications. Symptoms Altered mental status such as agitation, confusion, mania.
Discontinuation Syndrome – Autonomic dysfunction. Neuromuscular abnormalities.
Avoid rapid titration when changing Antidepressants, they require a gradual cease of the drug. It can
otherwise cause an uncomfortable range of symptoms from instant ceasing of medication.
Mania – Abnormally and persistently elevated, expansive, irritable mood. Abnormally and persistently
increased goal-directed activity or energy (lasting 1 week & present most of the day). Feeling rested after
very little sleep. Mania is more severe and prolonged and may require hospitalisation because symptoms are
more extreme.
Hypomania – Period of abnormally and persistently elevated, expansive, or irritable mood. Abnormally
and persistently increased activity or energy, and present most of the day. Symptoms are present in mania
but not hypomania as the severity is not enough to cause significant impairment in social or occupational
functioning to necessitate hospitalisation.
Psychosis – Collection of symptoms impairing a person’s understanding of reality with hallucinations
and delusions.
Borderline Personality Disorder – It includes a pattern of daily impulsivity, and unstable, intense
relationships, as well as an unhealthy way of seeing themselves. Where people have a lifelong pattern of
seeing themselves and reacting to others in ways that cause a level of impairment and emotional distress.
Delirium Tremens – A severe medical emergency of alcohol withdrawal (seen in heavy users)
characterised by rapid onset of confused state. Occurs within 1-5 days following cessation of alcohol.
Symptoms of agitation, confusion, paranoia, hallucinations, fluctuating blood pressure, nightmares.

RELAPSE – The Prodrome (The Warnings)

Early Warning Signs – Increased feelings of inadequacy. Increase in psychotic symptoms. Preoccupation
with self-improvement (looking for personal faults). Anxiety and restlessness. Changes in mood and sleep.
Loss of interest. Appetite changes. Irritability. Increases in risk taking. Poor maintenance of ADL’s.
Prevention – Consumer education. Early intervention. Medication or non-pharmacological treatments
and strategies to help the diagnosis before it gets worse. Insight and acceptance of illness and treatment.
Barriers to Recovery – Alcohol and drug use. Stigma. Disconnection from social support and community.
Lack of social confidence. Uncertainty about unpredictable nature of illness. Anguish that complete recovery
is not a possibility. Likelihood of relapse is very high after a manic episode. Majority of consumers will have
multiple episodes. Return to pre-morbid functioning will not be possible for many consumers.
LAW AND ETHICS
Invasive Treatments – Electroconvulsive therapy to treat Depression, Bipolar Disorder, Schizophrenia.
Trans magnetic stimulation, less invasive than ECT, for consumers who cannot tolerate pharmacological
treatment. Sedation and restraint use as per state law.
Ethics in Mental Health – Confidentiality, non-disclosure. Beneficence, non-maleficence, autonomy,
justice. Respect for diversity of mental health conditions. Respect for human dignity. Rather than managing a
patient’s symptoms, nurses work alongside the patients to reach their goals.
Legal Reasons with Medication – Legal reasons for someone to then have to take a certain medication.
Ethical reasons that it should not been forced on a person and should have the right to choose. Injections not
ideal for every person. Though it benefits consumers quality of life as the medication is to help them.

MEDICATIONS
Antidepressants – Dopamine antagonists, such as sertraline, fluoxetine and paroxetine.
Depot Medications – Risperidone oral dose initially. Then a long-acting injection monthly or so, etc.
Beta-blockers – For anxiety as these drugs block the action of adrenaline. Such as propranolol, atenolol.
Anxiolytics – For anxiety. Such as diazepam, clonazepam, lorazepam.
Mood stabilisers and Anti-Manics – For a medication to be considered a mood stabiliser, it must treat
and prevent both acute depression and mania.
Venlafaxine – A common short-term side effect of venlafaxine is anxiety. Venlafaxine is a long-term and
only an oral medication and should not be ceased abruptly. Antidepressants have been associated with
inducing rapid cycling/manic switching, inducing mania. More commonly associated with TCAs and
venlafaxine.
Olanzapine – Is a depot medication, in which it is a 2-4week acting medication administered as an
intramuscular injection.
Medication Risks – Use short term medications no greater than 2-3 weeks. Risk of drug addiction and
substance use disorder. Risk of drug dependence and reliance on mediation to manage symptoms.
Common Side Effects – Insomnia, sedation, orthostatic hypertension, increased risk of suicide.
Anti-cholinergic (delirium) effects: dry mouth, dry eyes, blurred vision, constipation, urinary retention.
Increasing restlessness, desire to pace, difficulty sitting or standing still.