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BNKN/NP601 EXAM 1 > Mental Health Assessment > Flashcards

Mental Health Assessment Flashcards

1
Q

What are the different types of risk?

A
  • Suicide/self-harm
  • Violence
  • Vulnerability
  • Alcohol/drugs
  • Falls
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2
Q

What is a Risk Assessment?

A

Assessment of potential or actual risk, considers risk to immediate self and others

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3
Q

What is a historical risk factor?

A

Known to be concrete, history cannot be changed (what have they done/doing)

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4
Q

What are contextual risk factors?

A

What is going on currently (clinical & internal factors may be positive or negative)

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5
Q

What are situational risk factors?

A

What is the current situation/altered risk? For example their relationship status or social situation

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6
Q

What are the components of a Mental Status exam? (MSE)

A
  • Appearance
  • Behaviour/activity
  • Speech
  • Mood
  • Affect
  • Thought content
  • Thought process
  • Concentration/Attention
  • Cognition
  • Insight
  • Judgement
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7
Q

What should we be looking out for with Appearence?

A
  • What they look like?
  • Posture
  • Appear stated age?
  • Grooming and hygiene (how they smell, are they scruffy?)
  • Comment on anything unusual
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8
Q

What should we be commenting on with Behaviour/activity?

A
  • 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
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9
Q

What should we be commenting on with Speech?

A
  • Quality and quantity of speech (are they using one-word answers or sentences?)
  • Are they talking fast or slow?
  • Are they interoperable?
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10
Q

What should we be commenting on with mood?

A
  • 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?
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11
Q

What should we be commenting on with affect?

A
  • 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)
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12
Q

What should we be commenting on with the thought process?

A
  • 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)
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13
Q

What are the 6 types of thought processes?

A

From organised to disorganised:

  1. Linear
  2. Circumstantial
  3. Tangential
  4. Loose associations
  5. Flight of ideas
  6. Word salad
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14
Q

What is Linear thought process?

A

Talking from point A-B in a direct and logical manner, you can easily follow the train of thought

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15
Q

What is circumstantial thought process?

A

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

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16
Q

What is Tangential thought process?

A

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.

17
Q

What is Loose Associations thought process?

A

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

18
Q

What is Flight of Ideas thought process?

A

Jumping from one topic to another in a constant stream of speech. Each topic is not related to the other

19
Q

What is Word Salad thought process?

A

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

20
Q

What should we be commenting on with Thought content?

A
  • 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
21
Q

What should we be commenting on with Attention/Concentration?

A
  • Ability to remain awake and focused or are they falling asleep
  • Are they alert
  • Do they appear distracted by noises in the room
22
Q

What should we be commenting on with Cognition - Memory

A
  • 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.
23
Q

What should we comment on with judgement?

A
  • 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
24
Q

What should we comment on with insight?

A
  • 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
25
Q

Why is a Functional Enquiry used?

A

A functional enquiry is an assessment which identifies changes in behaviour that have been effected by their illness

26
Q

What are the 9 parts of a functional enquiry?

A
  • Sleep
  • Enjoyment
  • Mood
  • Motivation
  • Appetite
  • ADL’s/self-care
  • Energy
  • Concentration
  • Anxiety
27
Q

What do nurses usually write their care plans from in Mental Health?

A

The Functional Enquiry and the MSE assessment, these questions are usually asked openly so will give broader information for each component

28
Q

What tools do mental health nurses use?

A
  • MSE (mental state exam)
  • Risk Assessment
  • Functional Enquiry
29
Q

Name and describe the 3 observation levels within mental health

A

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

30
Q

How should you ask about suicide?

A
  • “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

31
Q

What are some issues considered around the Risk Assessment?

A
  • Suicide
  • Substance misuse
  • Self Harm
  • Medical conditions (lack of ability to care for)
  • Self neglect
  • Financial problems
  • Vulnerability
  • Impulsivity

BNKN/NP601 EXAM 1 (5 decks)

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