Psych Assessment Flashcards
You are the captain of your own ship
Self efficacy
You are able to resist becoming I’ll in hard times
Hardiness
You bounce back quickly after a set back
Resilience
Including a lot of extra details that are not important when answering a question
Circumstantial
Can not comprehend they have an illness ( not the same as denial)
Anosognosia
Including a lot of extra details in answering a question - going on a tangent
Tangential
I am going to grumbulTe a conforum
Example of what altered speech pattern
Neologism
Altered perception and experience something that is not present
Hallucinations
Alexithymia
Difficulty expressing and identifying feelings
When you ask a client who has delirium a question their response will be
They will not understand the question
Asking a person with dementia a question , their response will look like
Answer , may sound reasonable to start but then start to wonder
- get different answer each time
Asking a depressed person a question their answer will look like
Short and may not be interested in convo
How is immediate / recall memory tested
3 objects recalled after several minutes
Red apple queen
How is recent memory tested?
Ask about memory - yesterday
Ex) how did you get to the hospital
How is remote/long term memory tested?
Ask about past memories
Akathisia
Motor restlessness
Isolative
Physically remove self from situations
- stays in bedroom
Withdrawn
Around others but does not engage
- not participating in group
Mood
Client states how they feel
Affect
How the patient appears to be feeling
- how nurse interprets
Labeled mood or affect
Swings or abrupt changes
Judgement
Can they act reasonably in urgent situations
- someone yells fire in a movie theater, what do you do?
Hypnagogic hallucinations
Happens when you are just about to fall asleep
Hypnopompic hallucinations
Happens when waking up
Delusion
Believing something that is not real
Impaired insight
Diminished ability to understand the objective reality of a situation
- do you think you do you think you need to be in hospital?
I do not need to be here! I am not suicidal!
Impaired judgement
Diminished ability to understand a situation correctly and act appropriately
- I can look after myself, I do not need money , I can live off the land ( has no home or resources)
Immediate recall loss
Patient cannot remember three things they were asked to remember 10 min ago
Suicidal ideation
Patient thinking about suicide most of time
Flat affect
No emotional expression
Blunted affect
Showing bits of emotion
Restricted affect
Showing one type of emotion
Labile affect
Going from one emotion expression to another, quickly and sometimes not matching the appropriateness of sitting
Somatic signs and symptoms
Observing facial grimacing and lip movements
Word salad
Incoherent mixture of words/ phrases
Thought blocking
Client starts answer then suddenly stops talking
Loose associations
Client makes a statement, expands on one word in the next while going in a different direction
Anti cholinergic toxicity
Increased hr , not able to void, no paristalsis , hot/ dry
Neuroleptic malignant syndrome (NMS)
Temp over 103, diaphoresis and rigid muscles
Physiological needs
Breathing food , water, sex, homeostasis, excretion
Safety needs
Security of body, employment, resources, family health
Love and belonging
Friends, family, sexual intensity
Self actualization needs
Morality, creativity, spontaneity, problem solving, lack of prejudice, acceptance of facts
Stage 1 : infancy - trust vs mistrust
Others will be reliable
Stage 2 : early childhood- autonomy vs shame and doubt
I can do things myself
Stage 3: preschool- initiative vs guilt
I can do things and I am a good person
Stage 4: school age - industry vs inferior
I am good at what I do
Stage 5: adolescence- identify vs confusion
A am a unique person, I belong
Stage six : early adult : intimacy vs isolation
I can be loved and love
Stage 7: middle age - generativity vs stagnation
I can contribute to the well being of others/ community, I have a purpose
Mini mental status exam (mmsu)
Considered psychiatric equivalent to physical exam
- count backward from 100 by 7s
Spell world backwards
Recall 3 words
Follow instructions for closing eyes / copy a drawing
Montreal cognitive assessment (MoCA)
More sensitive tool to assess orientation & memory
- connect dots in sequence 1-a 2-b..
Recall 5 words
Name animals
MSe or moca score for a Dementia patient
Be high - goes up with progression of illness
MSe - appearance
Appreciate/ well kept vs bizarre
Self care
Clothing , last shower?
Oral hygiene
MSE: level of consciousness
Alert and oriented vs not
Comatose, lethargic, delirious
MSe: orientation & memory
Oriented or disoriented, memory intact vs not
Time, date, place, self, situation
Immediate recall
Recent memory
Remote/ long term memory
MSe: perception and thought content
Reality based vs altered
- delusions, hallucinations, responding t internal stimuli
MSe: speech and thought process
Linear vs not liner
Organized / disorganized
Circumstantial, tangential, loose associations, flight of ideas, word salad….
Psychosis
Spit from reality
- common in schizophrenia, schizoaffective disorder, bipolar 1/2 , dementia, intoxication
Goals : day, stay, away
Goal for the day
Goal for hospital stay
Goal for discharge
Risk for violence to self or others
- 5 things to look out for
Ideation
Behavior
Palms
Intent
Psychosis
Strong predictors for suicide
Pervasive hopelessness
High intent
Recent attempts
Strong predictors for aggressive behavior
Current/ past violent behavior directed to hcp
Low frustration tolerance
Abnormal involuntary movement scale
Assessment tool for epse side effects of tar dive dyskinesia related to antipsychotic meds
- not reversible
Aims test for tar dive dyskinesia
Ask client to concentrate on movements such as finger tapping while observing other body parts for “activated movements”
Dto
Danger to others
Dts
Danger to self
