Chapter 11: The Psychiatric Mental Health Nursing Process Flashcards
Assessment
Assessment is the deliberate and systematic collection and interpretation of information or data to determine current and past health, wellness, strengths, functional status, and mental health problems, both actual and potential.
Open ended questions are most helpful when?
when beginning the interview because they allow the nurse to observe how the patient responds verbally and nonverbally. They also convey caring and interest in the person’s well-being, which helps to establish rapport.
Nurses should use closed-ended questions
when they need specific information.
ex; how old are you?
During mental status examination, general observations include:
These general observations include the patient’s appearance, affect, psychomotor activity, and overall behavior.
Mood
refers to the prominent, sustained, overall emotions that the person expresses and exhibits.
Terms used to describe mood include
euthymic (normal),
euphoric (elated),
labile (changeable), and
dysphoric (depressed, disquieted, and restless).
Affect
Affect refers to the person’s capacity to vary outward emotional expression.
Thought Processes
The nurse assesses the patient for rapid change of ideas; inability or taking a long time to get to the point; loose or no connections among ideas or words; rhyming or repetition of words, questions, or phrases; or use of unheard-of words. Any of these observations indicates abnormal thought patterns.
Self-concept
Self-concept, which develops over a lifetime, represents the total beliefs about three interrelated dimensions of the self: body image, self-esteem, and personal identity.
Self-concept is assessed through eliciting patients’ thoughts about themselves, their ability to navigate in the world, and their nonverbal behaviors.
Columbia Suicide Severity Rating Scale (C-SSRS)
is a commonly used, evidence-based measure used to identify and assess individuals at risk for suicide
