Summary

This section reviewed the components of a mental health history and mental status examination. The nurse must be able to identify factors that influence a mental health assessment, such as a patient’s culture, past experiences with mental health treatment, and communication barriers. The nurse can minimize the impact of these factors by ensuring that patients receive the most comprehensive assessment possible. Nurses must understand their role in performing mental status examinations. By understanding the components of the mental status exam, the nurse will gather data that will serve as the foundation upon which they will develop a comprehensive treatment plan for a patient. Nurses can also implement the interventions from the treatment plan, evaluate the effectiveness of the results, and revise the plans accordingly.

Upon completion of this section, you should be able to verbalize considerations the nurse must use when assessing a patient for alcohol abuse and illicit drug use. The nurse must understand and be able to describe various assessment measures for identifying illicit drug use in a patient. This includes knowing the special considerations that must be taken into account for specific populations when assessing for substance use.

The nurse will be able to describe their role in managing substance abuse. This includes a knowledge of the timeline and symptoms of withdrawal, lab values that may be expected in a patient with substance use disorder (SUD), and planning and evaluating interventions.

This section covered the different types of abuse nurses may encounter when assessing patients, ranging from child abuse and sexual abuse to elder abuse, coercion, and neglect. Nurses should never assume abuse but should learn to recognize obvious signs and symptoms of abuse and should use critical thinking to discern abusive situations that may not be quite as evident. Nurses should also be aware of the numerous negative health implications wrought by abuse. Victims of abuse often deal with physical, behavioral, and psychological problems as a direct or indirect result of their trauma or neglect. There are a number of assessment tools nurses can access to help determine a patient’s risk of being abused or resulting health issues. Nurses should be vigilant when treating patients who are considered more vulnerable, such as the very old or young, veterans, and people with disabilities, because they are at greater risk for abuse.