Mental Health Assessment Flashcards
What is mental health triage?
An assessment of behaviour, appearance, and conversation.
What must the allocation of a triage code be based on?
Clinical criteria that is consistent with ATS descriptors for acute behavioural disturbances and risk of harm to self or others.
What do we look for in terms of appearance? (Mental Health Triage)
Are they appear untidy, unkept, appropriate or inappropriate clothing, malnourished, dehydrated, intoxicated, flushed, dilated pupils, pinpoint pupils, tense, slumped over, bizarre postures, strange facial grimaces, and do they have any visible injurys.
What do we look for in terms of affect aka the patients current emotional state (Mental health triage)?
Is the patient flat, downcast, tearful, distressed, anxious, changing emotions rapidly, excessively happy and/or experiencing emotions inconsistent with what they are talking about.
What do we look for in terms of behaviour (Mental health triage)?
Is the patient restless, agitated, hyperventilating, tremulous, orientated, angry, hostile, uncooperative, over-familiar, suspicious, guarded, withdrawn, inappropriate, fearful, and/or refusing to talk.
Are they orientated, and/or responding to unheard voices or sounds, or unseen objects or people.
What do we look for in terms of conversation (Mental health triage) ?
Is their speech slurred, rapid, repetitive, slow, uninterruptible, loud, quiet, whisper, clear.
Are they angry.
Do they stop in the middle of a sentence because they are hearing voices.
Do they know what day and time it is and how they got to the ED.
What do we look for in terms of mood (Mental health triage)?
Does the patient say they feel low, down, worthless, depressed, sad, angry, irritable, anxious, fearful, sad, really happy or high, or cannot stop crying.
What is the ATS scale?
a clinical tool used to establish the maximum waiting time for medical assessment and treatment of a patient.
What makes up a holistic assessment?
MSE, Risk, Alcohol + other drugs, Functional Inquiry, Psychosocial, and Physical health.
What makes up an MSE?
Appearance, Behaviour, Mood/Affect, Thought form, Thought content, Perception, Cognition, Insight, and judgement
What do we look for in appearance in the MSE?
Facial expressions, Attire, Grooming, awareness - aka gives clues to personality and ability to preform ADLs
What do we look as apart of the behaviour component in the MSE?
How is the patient behaving (Body language, gait, posture, manner + gestures) + The patients speech (Rate, volume, intelligibility)
What do we look as apart of the Mood/Affect component in the MSE?
Affect: The patients immediate expression of emotion
Mood: The sustained emotional makeup of the patients personality
What do we look as apart of the thought form component in the MSE?
How the patients thoughts are strung together.
Rule of Thumb: If you can follow the patients conversation there is no thought disorder
What do we look as apart of the thought content component in the MSE?
What the patient is talking about (Suicidality, ruminations, anxiety, aggression, delusional, persecutory (you think someone is going to harm you))
What do we look as apart of the perception component in the MSE?
Check if the patient is having: Hallucinations, Preoccupations (obsessions), Depersonalisation, Derealisation, and Illusion
What do we look as apart of the cognition component in the MSE?
Check if the patient has: Delirium, or intoxication.
And assess concentration, attention, and memory
What do we look as apart of the insight component in the MSE?
Assess the patients understanding of their illness/disease: Terminology, aware of issues, realistic goals, and do they understand the difference between the patient and th Dr.
What do we look as apart of the judgement component in the MSE?
Is the patient able to judge situations?
and ensure their own physical and personal safety?
What is a question we may ask when assessing perception as apart of the MSE?
Do you hear any voices that only you can hear? i.e someone talking to you that is not my voice
What is a question we may ask when assessing judgement as apart of the MSE?
What would you do if you saw a fire in your bedroom?
What is a question we may ask when assessing mood as apart of the MSE?
On a scale of 1-10 with 1 being really sad, where do you see yourself today
What does a Functional Inquiry involve?
Energy (activity), motivation, sleep, appetite, enjoyment, anxiety, mood, and self care
What are some types of risk that we assess for?
Suicide, Self-harm, Violence, vulnerability, alcohol and other drugs.
How do we assess risk for a patient?
Ask about the patients history of common types of risk (what have they done and when), Preform a clinical assessment, and lastly ask about situational factors (Whats going on at home?)
What do we do with the information from our mental health assessments?
We formulate nursing care plans
Mental health professionals classify mental disorders using mainly which classification systems?
The DSM and ICD classification systems
Mental health assessment occurs in conjunction with a what?
Full clinical assessment
Assessment is foundational to the what?
Nursing process: Without assessment nursing care cannot exist
If an assessment is incomplete or incorrect, nursing interventions are likely to be ….
Inappropriate
What are some methods of Nursing Assessment?
Interviewing, Diaries (personal records), questionnaires, and observation.
Enhanced by collaboration
What may influence the nursing assessment?
Personal bias, stigma and discrimination, assumptions, and using a ‘one size fits all view’
What is thought form?
How the thoughts are strung together?
aka if you can follow the conversation there is no thought disorder
What is thought content?
What are they talking about? Suicide, ruminations, anxiety, aggression, delusional, or persecutory
What are persecutory delusions?
A person with persecutory delusions is unable to recognize reality. They strongly believe people or groups, like the government, intend to harm them.
The risk assessment considers?
History, External factors, Internal factors and Alcohol/Drug history
What are some external considerations for a risk assessment?
Relationships, sensory stimuli, surroundings, home, work ect
What are some internal/clinical considerations for a risk assessment?
Mental state, thoughts and feelings, coping stategies, personality, and use of alcohol and drugs.
What is an AOD
An alcohol and other drug assessment that includes smoking and medications.
What are static risk factors?
Factors that do not change or change in only one direction. Aka the patients history or age
What are dynamic risk factors?
Changeable features of individuals and their environments such as their relationships or work life
What are future risk factors?
Potential risks of harm to self or others based on static and dynamic risk factors
What are situational factors?
Social situations, relationship issues, legal issues, employment, finance, substance use, access to weapons, access to lethal means, drugs and alcohol
What factors influence risk exponentially?
Insight, misinterpretation, pain, impulsivity, and extreme or intense emotions.
What is an example of this risk: AWOL
The patients risk if they were to leave the ward/unit
What is an example of social vulnerability?
Being unable to read social situations accurately aka getting into a strangers car
What comes under ‘Formulation’ in a risk assessment?
How all risk factors fit together to identify low or high risk situations aka in which scenarios is the patient at the most risk of harm (Being left alone, or having access to certain items)
What is the timeline for completing a mental health assessment?
There is no specific timeframe, this may take days to complete.
What are Psychosocial factors?
Family/Whanau support, Community services, Sexuality, Cultural identifications, Developmental level, and Spiritual / wairua identifications.
What is a predisposing risk factor?
Predisposing factors are those that put a patient at risk of developing a problem
What is a precipitating risk factor?
Precipitating factors refer to a specific event or trigger to the onset of the current problem.
What is a perpetuating risk factor?
Perpetuating factors are those that maintain the problem once it has become established
What is a protective risk factor?
Protective factors are characteristics associated with a lower likelihood of negative outcomes or that reduce a risk factor’s impact.
