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
the perceptual disturbances part of the exam includes what?
- auditory hallucinations
- visual hallucinations
- tactile hallucinations
- olfactory hallucinations
- gustatory hallucinations
- illusions
- depersonalization (outside of themselves)
- derealization (strange environment)
how would you test a client to see if they’re capable of abstract thought?
-give them a proverb
the judgement and insight portion of the exam reveals what about a client?
- ability to solve problems and make decisions
- knowledge about self
- adaptive/ maladaptive coping strategies
WHat are the 5 axis?
1) clinical disorders such as schizophrenia, depression
2) personality disorders
3) medical conditions
4) phsychosocial and environmental problems
5) global assessment of functioning score
