MSE ASSESSMENT Flashcards
Purpose of a Pysch assessment
- 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
Mental Health Assessment (purpose and function)
•Purpose
–Objectively determines and records aspects of the patients mental/psychological processes
•Function
–Substantiates and organizes clinical observations and sets a baseline
Assessment Process
- Personal history
- Presenting Problem
- History of Presenting Problem
- Medical history (including substance abuse)
- Mental status exam (including self harm)
- Formulation
- Recommendations
Mental status exam
- General observations
- Mood
- Affect
- Speech characteristics
- Perception
- Thinking
- Sensorium
- Insight
- judgement
observation
•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
affect
•Affect = observable expression of mood
–Flat
–Blunted
–Labile
–euphoria
mood
•Mood = objective feeling state
–Fearful
–Anxious
–Sad
–Panic
–angry
assessment of mood and affect
•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
assessment of cognition
- Orientation
- time
- person
- place - Memory
- immediate
- short term
- recent
- remote - Concentration
- serial 7’s or 3’s - Proverbs
- concrete or abstract thinking
- similarities and differences - Judgment
- and Insight
thought process
•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
examples of disturbed thought process
- Word salad
- Clang associations
- Echolalia
- Verbigeration
- Pressured speech
- neologisms
thought Content
•Direct questioning
–Check with others
–Assess for disturbance in functioning of thoughts
•Look for:
–Recurrent themes
–Obsessions
–Neologisms
–Ideas of reference
–delusions
delusions of control
- Thought insertion/withdrawal
- Thought broadcasting
- Ideas of reference
Perception
•Direct questions
–Hallucinations
–Illusions
–Depersonalization
–Derealization
•Observations
–Unusual behaviours, talking/laughing to self, responding to unseen stimuli, air picking, skin picking
sensorium
- LOC
- Orientation
- Memory
- Attention & concentration
- Comprehension & abstract reasoning
insight
•Insight
–What does your patient think about their illness?
–Have they sought treatment or were they committed?
judgement
•Judgement
–Patterns of decision making
–Choices they’ve made
–Problem solving abilities
–“what would you do…” type questions
emotion focused coping
- changes perception of the stressor
- Divert attention away by changing the meaning the person assigns to it
problem focused coping
changes an element of the person-environment relationship
DSM 5
- Diagnostic and Statistical Manual of Mental Disorders
- Improves the reliability of diagnostic judgement
- Safeguards the client from inaccurate diagnosis
- Includes 5 Axis
Axis I
Clinical Disorders
–schizophrenia
–anxiety disorders
–affective disorders
–somatoform disorders
–dissociative disorders
–anorexia
–substance abuse
Axis II
Personality Disorders
–antisocial
–borderline
–compulsive
–passive-aggressive
Axis III
General Medical Conditions
–cardiovascular disease
–diabetes
–Obesity
–Cancer
–Alzheimer’s
Axis IV
-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
Axis V
Global assessment of functioning
–Highest level of adaptive functioning in the last year and currently
–rated from superior to grossly impaired
–Numerical Value assigned
Lab work and medication considerations
- Consider relevant lab work in assessment:
Renal & hepatic function
Medication levels (lithium)
WBC counts (clozaril)
Drug/ETOH screen
Vitamin B12
Electrolytes – Na+ - Medication regime
Interactions
Side effects
social communication
- 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
therapuetic communication
- 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
criteria for certification
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.
how long is the form 2 (renewel certificate) good for?
1 month
how long is form 2 good for? (3rd renewal)
6 months
which form can a peace officer give?
form 10
which form can a judge give?
form 7 and 8
how does an admission certificate work (made by physician)?
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
what is a form 12?
application for review of certificates
what is a form 11?
–Request to the Review Panel (FORM 11) for a treatment order
•A physician fills out a Form 11 which deems the patient incompetent
how long can patient be held on a form 1?
24 hours
