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PSYCHOLOGY > MSE ASSESSMENT > Flashcards

MSE ASSESSMENT Flashcards

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1
Q

Purpose of a Pysch assessment

A
  • Establish rapport
  • Obtain understanding of problem
  • Assess psychological functioning
  • Perform mental status examination
  • Identify behaviors/beliefs/areas to be modified to effect positive change
  • Identify goals and interventions
  • Formulate a plan of care
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2
Q

Mental Health Assessment (purpose and function)

A

•Purpose
–Objectively determines and records aspects of the patients mental/psychological processes
•Function
–Substantiates and organizes clinical observations and sets a baseline

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3
Q

Assessment Process

A
  • Personal history
  • Presenting Problem
  • History of Presenting Problem
  • Medical history (including substance abuse)
  • Mental status exam (including self harm)
  • Formulation
  • Recommendations
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4
Q

Mental status exam

A
  • General observations
  • Mood
  • Affect
  • Speech characteristics
  • Perception
  • Thinking
  • Sensorium
  • Insight
  • judgement
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5
Q

observation

A

•Appearance
–Clothing, posture, cosmetics, appropriateness, general hygiene, tattoos, facial features, bruising or needle marks, pallor, nutritional status
•Psychomotor activity
–Energy level, gestures, gait, coordination, activity, eye contact, expressions
•Attitude toward interviewer or process
–Accommodating, cooperative, open bored, guarded, suspicious, hostile, evasive

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6
Q

affect

A

•Affect = observable expression of mood
–Flat
–Blunted
–Labile
–euphoria

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7
Q

mood

A

•Mood = objective feeling state
–Fearful
–Anxious
–Sad
–Panic
–angry

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8
Q

assessment of mood and affect

A

•Consider:
– congruence to environment, development, situation
–Safety, stability
–Changes from usual
•Descriptors:
–Downcast, bright, flat, blunted, labile
–Whatever the pt states concerning mood: “I am so sad and hopeless” = mood state

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9
Q

assessment of cognition

A
  1. Orientation
    - time
    - person
    - place
  2. Memory
    - immediate
    - short term
    - recent
    - remote
  3. Concentration
    - serial 7’s or 3’s
  4. Proverbs
    - concrete or abstract thinking
    - similarities and differences
  5. Judgment
  6. and Insight
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10
Q

thought process

A

•attends to rate & flow of thoughts
•Interruption in train of thought
–thought blocking
•Disturbance of thought association & organization
–flight of ideas
–circumstantial/tangential/loose associations
•Disturbance in rate of speech
–pressured
–slow

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11
Q

examples of disturbed thought process

A
  • Word salad
  • Clang associations
  • Echolalia
  • Verbigeration
  • Pressured speech
  • neologisms
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12
Q

thought Content

A

•Direct questioning
–Check with others
–Assess for disturbance in functioning of thoughts
•Look for:
–Recurrent themes
–Obsessions
–Neologisms
–Ideas of reference
–delusions

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13
Q

delusions of control

A
  • Thought insertion/withdrawal
  • Thought broadcasting
  • Ideas of reference
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14
Q

Perception

A

•Direct questions
–Hallucinations
–Illusions
–Depersonalization
–Derealization
•Observations
–Unusual behaviours, talking/laughing to self, responding to unseen stimuli, air picking, skin picking

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15
Q

sensorium

A
  • LOC
  • Orientation
  • Memory
  • Attention & concentration
  • Comprehension & abstract reasoning
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16
Q

insight

A

•Insight
–What does your patient think about their illness?
–Have they sought treatment or were they committed?

17
Q

judgement

A

•Judgement
–Patterns of decision making
–Choices they’ve made
–Problem solving abilities
–“what would you do…” type questions

18
Q

emotion focused coping

A
  • changes perception of the stressor
  • Divert attention away by changing the meaning the person assigns to it
19
Q

problem focused coping

A

changes an element of the person-environment relationship

20
Q

DSM 5

A
  • Diagnostic and Statistical Manual of Mental Disorders
  • Improves the reliability of diagnostic judgement
  • Safeguards the client from inaccurate diagnosis
  • Includes 5 Axis
21
Q

Axis I

A

Clinical Disorders
–schizophrenia
–anxiety disorders
–affective disorders
–somatoform disorders
–dissociative disorders
–anorexia
–substance abuse

22
Q

Axis II

A

Personality Disorders
–antisocial
–borderline
–compulsive
–passive-aggressive

23
Q

Axis III

A

General Medical Conditions
–cardiovascular disease
–diabetes
–Obesity
–Cancer
–Alzheimer’s

24
Q

Axis IV

A

-Psychosocial and Environmental Problems
-Economic problems
-Problems with access to health services
-Problems related to interaction with the legal system
–Nursing diagnosis are often based on these psychosocial and environmental problems

25
Q

Axis V

A

Global assessment of functioning
–Highest level of adaptive functioning in the last year and currently
–rated from superior to grossly impaired
–Numerical Value assigned

26
Q

Lab work and medication considerations

A
  1. Consider relevant lab work in assessment:
    Renal & hepatic function
    Medication levels (lithium)
    WBC counts (clozaril)
    Drug/ETOH screen
    Vitamin B12
    Electrolytes – Na+
  2. Medication regime
    Interactions
    Side effects
27
Q

social communication

A
  • No definite goals set
  • No responsibility required
  • Commitment to the relationship is optional
  • Potential for mutual sharing of problems
  • Skills not necessary
  • No obligation to maintain confidentiality
28
Q

therapuetic communication

A
  • Goal directed
  • Responsibility to use skill
  • Commitment to the goals of care
  • Professional boundaries evident
  • Mutual respect, not mutual intimacy
  • Skills needed and developed
  • Confidentiality stated
29
Q

criteria for certification

A

a) suffering from a mental disorder
b) Likely to cause harm to the person or others or to suffer substantial mental or physical deterioration or serious physical impairment, and
c) unsuitable for admission to a facility other than a formal patient.

30
Q

how long is the form 2 (renewel certificate) good for?

A

1 month

31
Q

how long is form 2 good for? (3rd renewal)

A

6 months

32
Q

which form can a peace officer give?

A

form 10

33
Q

which form can a judge give?

A

form 7 and 8

34
Q

how does an admission certificate work (made by physician)?

A

a Physician completes an admission certificate (within 24hrs of examination); this certificate authorizes the conveyance within 72 hrs and can HOLD a patient against his/her will x 24 hrs

35
Q

what is a form 12?

A

application for review of certificates

36
Q

what is a form 11?

A

–Request to the Review Panel (FORM 11) for a treatment order

•A physician fills out a Form 11 which deems the patient incompetent

37
Q

how long can patient be held on a form 1?

A

24 hours

38
Q
A

PSYCHOLOGY (17 decks)

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