Mental Health Assessment Flashcards
What are the different types of risk?
- Suicide/self-harm
- Violence
- Vulnerability
- Alcohol/drugs
- Falls
What is a Risk Assessment?
Assessment of potential or actual risk, considers risk to immediate self and others
What is a historical risk factor?
Known to be concrete, history cannot be changed (what have they done/doing)
What are contextual risk factors?
What is going on currently (clinical & internal factors may be positive or negative)
What are situational risk factors?
What is the current situation/altered risk? For example their relationship status or social situation
What are the components of a Mental Status exam? (MSE)
- Appearance
- Behaviour/activity
- Speech
- Mood
- Affect
- Thought content
- Thought process
- Concentration/Attention
- Cognition
- Insight
- Judgement
What should we be looking out for with Appearence?
- What they look like?
- Posture
- Appear stated age?
- Grooming and hygiene (how they smell, are they scruffy?)
- Comment on anything unusual
What should we be commenting on with Behaviour/activity?
- Attitude towards the interviewer
- What are they doing?
- Are they polite and open? or more closed off
- Eye contact
- Are they sitting calm, or agitated
- Is their gait normal or unsteady
- Comment on anything unusual
What should we be commenting on with Speech?
- Quality and quantity of speech (are they using one-word answers or sentences?)
- Are they talking fast or slow?
- Are they interoperable?
What should we be commenting on with mood?
- Record what the patient says when you ask ‘How is your mood’
- If the patient answers vaguely, then ask more questions
- Ask ‘on a scale from one-ten (1 being sad) where would you put yourself?
What should we be commenting on with affect?
- How do they look like they are feeling?
- Describe their observable emotional state
- First describe their overall emotional tone, do they seem anxious? angry? euphoric?
- Next comment on the emotional range and liability (do they have limited emotional expression?, does it change from happy one second to tearful the next)
What should we be commenting on with the thought process?
- The connection between thoughts
- What is their thinking like?
- Is it organised or not?
- Describe the connection between thoughts
- Clanging (words are chosen on their sounds and rhythm)
What are the 6 types of thought processes?
From organised to disorganised:
- Linear
- Circumstantial
- Tangential
- Loose associations
- Flight of ideas
- Word salad
What is Linear thought process?
Talking from point A-B in a direct and logical manner, you can easily follow the train of thought
What is circumstantial thought process?
Start at point A, and add many irrelevant details. They eventually get to point B, but it does take a while. They share material that is not relevant to the purpose. May seem like they are getting off-topic, but then brings it back
What is Tangential thought process?
Frequently gets off topic and never brings it back. They start at point A and never makes it to point B. The interviewer often feels lost as they are not getting the story.
What is Loose Associations thought process?
Jumps to topics that are only marginally related. Starts at point A, jump to point U and then D etc. and never makes it to point B
What is Flight of Ideas thought process?
Jumping from one topic to another in a constant stream of speech. Each topic is not related to the other
What is Word Salad thought process?
Speaking in such a way that there is no connection from word to word. Everything is jumbled and you can not follow their train of thought
What should we be commenting on with Thought content?
- Suicidal or homicidal intention
- Mix of what the patient says (subjective) and what you observe (objective)
- Seeing Delusions and hallucinations that others don’t
- Preoccupations, obsessions, ruminations
- Comment on behaviours you observe that point towards being psychotic
What should we be commenting on with Attention/Concentration?
- Ability to remain awake and focused or are they falling asleep
- Are they alert
- Do they appear distracted by noises in the room
What should we be commenting on with Cognition - Memory
- Can the patient remember? Both short and long term memory
- Can the patient answer questions about their past?
- Comment on memory related to their own experiences as well as general knowledge
- Can they tell you their medications and what doses? or even more personal questions
- Formal memory test is the 3-word recall where you tell the patient 3 things to remember and you get them to tell you those words a few minutes later.
What should we comment on with judgement?
- Are they able to make reasonable decisions?
- Ask the patient what they would do if the fire alarm sounds
- Are they feeling safe at the hospital
What should we comment on with insight?
- Do they understand their situation?
- Do they know they are sick? Or do they think there is nothing wrong with them
- Do they understand why they are at the hospital
Why is a Functional Enquiry used?
A functional enquiry is an assessment which identifies changes in behaviour that have been effected by their illness
What are the 9 parts of a functional enquiry?
- Sleep
- Enjoyment
- Mood
- Motivation
- Appetite
- ADL’s/self-care
- Energy
- Concentration
- Anxiety
What do nurses usually write their care plans from in Mental Health?
The Functional Enquiry and the MSE assessment, these questions are usually asked openly so will give broader information for each component
What tools do mental health nurses use?
- MSE (mental state exam)
- Risk Assessment
- Functional Enquiry
Name and describe the 3 observation levels within mental health
Level 1 - Need to be very close to patient in case they try and harm themselves you can stop them or call your alarm
Level 2 - Need to still be quite close in case they try and harm themselves but can stand further away
Level 3 - 15 minute observations or so. Trust your gut instinct and if you think you need to go check on your patient, then go do it
How should you ask about suicide?
- “Have you had thoughts of hurting yourself or others?”
- “Do you have any feelings of suicide?”
- “What access do you have?” - hanging, tablets, poisons, cutting, gun
- “Does it seem unbearable at times?”
- Ask about a timeframe (when) and what would stop them
The person is more likely to appreciate straightforward questions and feel relieved about talking about how they feel
What are some issues considered around the Risk Assessment?
- Suicide
- Substance misuse
- Self Harm
- Medical conditions (lack of ability to care for)
- Self neglect
- Financial problems
- Vulnerability
- Impulsivity
