Psychiatric and Mental Health Nursing
Domain 5 tests mental state assessment, therapeutic communication, suicide and crisis management, psychotropic monitoring, and the legal framework - including Kenya's Mental Health (Amendment) Act 2022, which replaced the 1989 Act and decriminalised attempted suicide.
Mental state examination
Appearance and behaviour; speech; mood and affect; thought form and content; perception (hallucinations, illusions); cognition; insight; and risk. Risk is assessed last but acted on first.
Therapeutic communication
Use open questions, reflection, clarification and silence. Avoid "why" questions, false reassurance, arguing with delusions, and colluding with them - instead acknowledge the feeling and redirect.
Suicide risk
Ask directly ("Are you thinking of killing yourself?"), then assess plan, means, intent and previous attempts. Remove means, maintain observation at the level prescribed, and document.
Drug monitoring
- Antipsychotics: extrapyramidal effects (dystonia, akathisia, parkinsonism, tardive dyskinesia).
- Neuroleptic malignant syndrome: fever, rigidity, autonomic instability, raised creatine kinase - stop the drug and escalate.
- Lithium: therapeutic range roughly 0.6–1.2 mmol/L; toxicity causes tremor, vomiting and ataxia, worsened by dehydration, NSAIDs and diuretics.
- Clozapine: monitor full blood count for agranulocytosis.
Worked example
A patient on haloperidol for three days develops temperature 39.5 °C, lead-pipe rigidity, confusion, BP 170/100 and pulse 130. Reasoning: this is neuroleptic malignant syndrome, not sepsis alone. Stop the antipsychotic immediately, escalate, cool the patient, give IV fluids, monitor creatine kinase and renal function, and treat complications. Restarting the same drug at the same dose is a trap.
Traps
Using restraint without a prescription, documented indication or 15-minute monitoring; assuming a calm patient carries no suicide risk; discussing a delusion as if it were true.