Objective 2 Flashcards
what are the categories of psychiatric history?
current condition
previous diagnosis
previous interventions and treatments
family history
what are the categories of data?
complaint/reason for admin
present symptoms
previous hospitalizations and treatments
personal history
personality
what is the significance of psychiatric mental health nursing assessment?
Establish rapport
* Obtain understanding of current problem
* Review physical status and obtain baseline VS
* Assess risk factors associated with safety of patient or
others
* Perform a mental status assessment
* Assess psychosocial status
* Identify mutual goals for treatment
* Formulate a plan of care
Useful tools include storytelling, dolls, drawing, and
games to promote disclosure
assessment of children
Particularly concerned about confidentiality
Threats of suicide or homicide, use of illegal drugs, or
issues of abuse cannot be kept confidential and must
be shared with other professionals and parents
assessment of adolescents
Be aware of physical limitations such as a sensory,
motor, or medical condition that could cause
increased anxiety, stress, or physical discomfort for
the patient
Make accommodations at the beginning of the
interview when possible (hearing, sight)
High pitch voice may increase anxiety
Sit close but not to invade the pt’s personal space
assessment of older adults
steps of cultural competence during assessment
- Assess and clarify the client’s cultural values, beliefs,
and norms - Assess the client’s degree of cultural
assimilation/acculturation - Assess the client’s perspective regarding feelings and
symptoms - Elicit the client’s expectations and ask what is
important for the health care provider to know - Learn how to work with interpreters
- When using an interpreter, talk to the client rather
than the
interpreter (observe eyes/face for nonverbal) - Seek collaboration with bilingual community
resources (social
worker in meeting)
Review of systems
Laboratory data
Mental status examination [MSE] (Box 6-3)
Psychosocial assessment (Box 6-4)
Spiritual/religious assessment
Cultural and social assessment
Standardized nursing assessment tools facilitate the
assessment process (Table 6-2)
gathering data
(old medical records, family)
validate data
what do we assess during mental status assessment?
intelligence
thought processes
capacity for insight
Data related to client’s
Biological
Psychological
Cultural
Spiritual
Social needs
* Completed in collaboration with other health
care professionals
comprehensive assessment
Collection of data regarding a particular
problem as determined by:
Client
Family member
Crisis situation
focused assessment
Collection of predetermined data usually during initial
contact, to determine how client is functioning in various
areas
* Includes use of assessment or rating scales to evaluate
data regarding a specific problem (memory loss or
insomnia) or behavior (combativeness or impulsivity)
screening assessment
A type of screening assessment that can be used in
variety of settings to describe appearance, speech, mood,
thinking, perceptions, sensorium, insight and judgment
psychiatric mental status exam
Screens for cognitive impairment and dementia
Used to estimate level of cognitive impairment
at a given point in time
The maximum score is 30. A score of 23 or lower
is indicative of cognitive impairment
Takes only 5-10 minutes to administer and is
therefore practical to use repeatedly and
routinely
Folstein’s mini mental state exam
what is the purpose of the mental status exam?
Gather objective data.
* Deal immediately with any
risk of violence or harm.
* The MSE can change from
day to day or hour to hour
* It is the description of the
patient’s appearance,
speech, actions, and
thoughts throughout the
interview.
Psychological equivalent of a physical exam that
describes the mental state and behaviors of the
person being seen including objective
observations and subjective descriptions
provided by the client
* Provides information for the diagnosis and
assessment of disorder and response to
treatment
* A mental status exam provides a snap shot at a
point in time
mental status exam
what are the steps in collection of data
appearance
affect or emotional state
behaviour, attitude, and coping patterns
communication and social skills
content of thought
orientation
memory
intellectual ability
insight regarding illness
spirituality
sexuality
neurovegetative changes
A form of nonverbal communication where
thoughts feelings and moods and conveyed
appearance
what do we observe during appearance?
Apparent age (relationship between appearance &
age)
* Peculiarity of dress
* Cleanliness (hygiene & grooming)
* Use of cosmetics
* Pupil dilation, facial expression
* Height, weight, nutritional status
* Present of scars, tattoos, body piercings
Body movements
Level of eye contact (be mindful of cultural
differences)
behaviour (observed)
Rate & tone
Volume
Disturbances
Cluttering
speech (observed)
what do we observe when assessing behavior attitude and oping patterns?
suicide
violence
substance abuse
Emotional experience over prolonged period of
time
Tone (sad, euphoric, depressed)
Degree (mild, moderate, extreme)
Irritability (calm, irritable, explosive)
Stability (rapid or delayed)
mood (inquired)
Immediate expressions of emotions
Range
Appropriateness & Stability
affect (observed)
An individual’s present emotional
responsiveness
Temporary expression of feelings or state of
mind
Nonverbal
Facial expressions, gestures
Differs from mood
Are the two congruent?
Affect can be incongruent from what one says or
does
affect or emotional state
Severe reduction or limitation in intensity of one’s
affective response to a situation
blunted
Absence or near absence of signs of affective
responses (immobile face, monotonous tone of voice)
flat
Discordance (lack of harmony) between one’s voice and
movements with one’s speech or verbalized thoughts
inappropriate
Abnormal fluctuation or variability of one’s expressions
(repeated, rapid or abrupt shifts)
labile
Reduction in one’s expressive range and intensity of affective responses
restricted or constricted
what are the factors to consider when assessing attitude?
Is behaviour strange, threatening, suicidal, self injurious
or violent?
* Is client trying to control emotions?
* Any unusual mannerisms or motor activity such as
grimacing, tremors, tics, impaired gait, psychomotor
retardation or agitation? Excessive pacing?
* Are they friendly, embarrassed, fearful, resentful,
angry, negativistic or impulsive?
* Attitude toward interviewer or others can facilitate or
impair the assessment process
* Is behaviour overactive or hyperactive? Is it purposeful,
disorganized, stereotyped?
* Are actions consistent?
what are the communication and social skills for impaired communication?
blocking
circumstantiality
clang association
echolalia
flight of ideas
looseness of association
mutism
neologism
perseveration
tangentiality
verbigeration
word salad
Disorganized, coherent, flight of ideas,
neologisms, thought blocking, circumstantiality
thought process
Delusions, jealousy, thought
control/withdrawal/insertions, obsessions or
preoccupations
thought content
Fixed or false beliefs not true to fact & not ordinarily
accepted by other
Occur in clients with various psychotic disorders
delusions
what are the types of delusions frequently reported?
Delusion of reference or persecution
* Delusion of alien control
* Nihilistic delusion
* Delusion of poverty
* Delusion of grandeur
* Somatic delusion
Feeling of unreality or strangeness concerning self, environment or
both
* Clients describe out of body experiences
* Common in schizophrenia, bipolar disorders, depersonalization
disorders
depersonalization
what are the obsessions of content of thought?
Insistent thoughts, recognized as arising from self
* Seen in those with anxiety or obsessive compulsive disorder
what are the compulsions associated with content of thought?
Insistent, repetitive, intrusive and unwanted urges to perform an
act contrary to one’s ordinary wishes or standards
* Repetitive urge to gamble although partner threatens divorce if
don’t stop playing poker
* If don’t engage in act, feel tension and anxiety
* Seen in those with anxiety, obsessive compulsive disorder or
personality body dysmorphic, eating or autism spectrum disorders
Sensory perceptions in the absence of an actual
external stimulus
hallucinations
what are the types of hallucinations?
auditory
visual
olfactory
gustatory
tactile
Hears voices frequently telling client when to eat, dress and
go to bed each night
auditory
Describes seeing spiders and snakes on ceiling of room
visual
States “smells rotten garbage” but not evidence of any foul
smelling material
olfactory
Complains of constant taste of salt water in mouth
gustatory
Client going to alcohol withdrawal and delirium tremens
tactile
Misperception of a real external stimulus such as, noise
or shadows
* Ex: dementia patients interpret rustling of leaves as
voices
* Also common in symptoms of withdrawal from
alcohol/other substances
illusions
what are the common dissociations for illusions?
Feeling detached, surroundings not real
what are the things to looks for when assessing cognition (inquired)?
Orientation (person, place, time)
Level or consciousness (alert, confused, stuporous)
Memory functioning (remote, recent, immediate)
General Knowledge (compared to average person)
Language (following instructions)
Attention (performance on tests with #’s)
Abstraction (performance on tests with similarities)
Visual or special processing
Insight (self-understanding)
Judgement (problem-solving)
what are the things to look for when you assess orientation?
1.Person
2.Place
3.Time
4.Level of orientation and consciousness
Confusion
Clouding of consciousness
Stupor
Delirium
Coma
Disorientation to person, place or time, characterized by
bewilderment and complexity
confusion
Disturbance in perception or thought that is slight to moderate,
usually due to physical or chemical factors producing functional
impairment of the cerebrum
clouding of consciousness
A state in which the client does not react to or is unaware of his
or her surroundings. May be motionless and mute but conscious
stupor
Confusion accompanied by altered or fluctuating
consciousness. Moderate to severe disturbance in emotion,
thought and perception, usually associated with infections,
toxic states, head trauma, etc
delirium
Ability to recall events in the immediate past and for up
to 2 weeks previously
recent memory
Ability to recall remote past experiences such as the
date and place of birth, names of schools attended,
occupational history, chronologic data related to
previous illnesses
long-term memory
what are some memory disorders?
hypermnesia
amnesia
paramnesia
abnormally pronounced memory
hyperamnesia
loss of memory
amnesia
falsification of memory
paramnesia
Ability to use facts comprehensively
intellectual ability
what must u ask a pt when assessing intellectual ability?
Names of persons or places (last three Prime
Ministers)
Mathematical questions (calculate simple math
problems)
Ability to form opinions (what would you do if you
found a wallet in front of your house?)
Make distinctions between abstractions
Interpret simple fables or proverbs
abstract thinking
Self understanding or the extent of one’s
understanding about the:
Origin
Nature
Mechanism of one’s attitudes or behaviour
insight
Should determine
Denomination
Beliefs
Spiritual practices
Spiritual support system
Are beliefs used as a coping mechanism?
spirituality
Use non-gender-specific terms during interview
(eg: partner, them/they)
* Sexual identity
* Gender identity
* Sexual orientation
* Assess client’s comfort level when discussing
sexuality
sexuality
what are neurovegetative changes?
sleep patterns’
eating patterns’
energy levels
sexual functioning
elimination patters
Asking clients about their sleep patterns
and any problems with sleeping is an often-
neglected, but extremely important, area
to investigate:
* Insomnia
* Acute or primary insomnia
* Secondary insomnia
sleep patterns
Difficulty initiating and maintaining sleep
insomnia
Sleepiness and alertness that occur at an inappropriate
time of day relative to local time, occurring after repeated
travel across more than one time zone
jet lag
Overwhelming sleepiness in which irresistible attacks of
refreshing sleep, cataplexy (loss of muscle tone) and/or
hallucination or sleep paralysis at beginning or end of
sleep episodes
narcolepsy
Repeated awakenings from major sleep or naps with
detailed recall of extended or extremely frightening
dreams, usually involving threats to survival, security or
self esteem
nightmare disorder
Characterized by insomnia associated with crawling
sensations in lower extremities, frequently associated
with medical conditions such as arthritis or pregnancy
restless leg syndrome
Breathing related sleep disorder due to disrupted
ventilation or airway obstruction with lack of airflow.
Normal sleeping pattern completely disrupted several
times throughout night
sleep apnea
Recurrent episodes of abrupt awakening from sleep
usually accompanied by panicky scream, intense fear,
tachycardia, rapid breathing and diaphoresis
* unresponsive to efforts of others to provide comfort
and no detailed dream recall
sleep terror disorder
how do we assess for ideas of harming self or others?
Inquire about suicidal or homicidal thoughts
Target (self or other)
Frequency
Intent
Plan (Lethality of means, means or opportunity to
carry out the plan
how do we assess pain?
Assess level of pain using pain intensity age-
appropriate rating scale
Client self report of pain most reliable indicator
If unable to verbally communicate look at
nonverbal
Information is used to
plan treatment.
* Develop nursing diagnosis.
* Predict outcomes
* Set goals for client
behavior.
* Measure impact of
treatment
* Evaluate client response to
goal/treatment.
global assessment of functioning
a handbook for mental
health professionals that lists different
categories of mental disorders and
the criteria for diagnosing them
The manual has been revised six
times since its inception
Organizes each psychiatric diagnosis
according to different aspects of a
specific disorder or disability
DSM-V
informal supporters or caregivers are prone to:
depression
anxiety
grief
fatigue
changes in social relationships
other issues
what do we document for assessment data?
Objective
* Descriptive
* Complete
* Legible
* Dated
* Logical
* Signed
