Nursing Assessment of Psych Patients Flashcards
What are the 6 standards of the psychiatric nursing process ?
- assessment
- diagnosis
- outcomes identification
- planning
- implementation
- evaluation
During step 5, what should the nurse be aware of/ responsible for?
- coordination of care between different members
- health teaching and promotion
- milieu therapy in order to provide a safe and therapeutic environment
- pharmacological, biological and integrative therapies
What is the general outline of a nursing assessment in mental health?
- general info/ demographics
- predisposing/ familial factors
- precipitating event
- client’s perception to the stressor
- adaptation responses
- physical assessment
- mental status exam
What are the components of a mental status exam?
-appearance
-behavior/motor activity
-LOC
- orientation to person, place, time and situation
-memory
-speech
-mood
-affect
-associations
-perceptual disturbances
-thought content
-delusions
impulse control
-insight
-judgement
-abstract vs. concrete
grooming, dress, hygiene, posture, height, weight, eye contact, hair texture/color evidence of scars, birthmarks and tattoos as well as client’s appearance compared to chronological age are all examples of what part in the mental status exam?
-appearance
if i say a client has tics, is biting his nails, unable to sit still is restless, he uses sarcasm and his posture is slumped, what part of the mental status exam am i referencing?
-motor behavior
a client states their correct name and place but they cannot tell you the date or situation what is their orientation score?
x2 orientated to name and place
T/F: Speech patterns include rate, intonation, volume, impairments, aphasia and emphasis of message.
-true
when a client is ecstatic in one moment and crying the next their mood is considered?
-labile
when a client’s affect is congruent what does that mean?
- emotional expression is consistent with their body language
examples of a client’s affect includes?
- congruence
- blunted
- flat
- appropriate
- innapropiate
if a client knows why they’ve been admitted to the unit and understands that they need help their thought associations would be rated as?
-tight
give at least 4 examples of thought processes?
1) flight of ideas
2) associative looseness
3) circumstantial
4) tangible
5) neologisms
6) concrete thinking
7) word salad
8) perseveration
name 6 delusions
1) persecutory
2) grandiose
3) reference
4) control or influence
5) somatic
6) nihilistic
the thought content part of the exam includes which of the following: delusions, suicide or homicide idealization, obsessions, religiosity, affect, phobias, speech rate, paranoia and general attitude.
includes all EXCEPT affect, speech rate and general attitude
