Psychiatric Health Assessment Midterm Flashcards
5Ss of taking a Psychiatric History
Symptoms
Social
Substances
Psychosis
Self Harm
If a patient does not have risk factors associated with suicide then they are considered no risk for suicide.
T or F
False - no risk factors does not exclude risk
What is the best Pneumonic for the Psychiatric Interview
CHAMPIONS PSYCH EVAL
What does CHAMPIONS stand for in CHAMPIONS PSYCH EVAL
Chief Compliant
How can I help?
Assessment
Medical History
Psych History
Ideation (suicidal & homicidal)
Orientation (person/place/time/situation)
Navigation (safe - environment)
Social Support
What does PSYCH EVAL stand for in CHAMPIONS PSYCH EVAL
Prescriptions
Substances
Youth Development
Collateral (outside perspectives)
Housing
Employment
Victimization
Ancestry
Legal Issues
What are the 4 tasks of the Psychiatric Interview?
- Build a therapeutic alliance
- Obtain a Psych Hx
- Interview for Diagnosis
- Negotiate a tx plan and communicate it to your patient
Is the Diagnostic Interview about treatment or diagnosis?
Treatment!
Name 3 reasons pts do not return after the initial interview
- Poor rapport/alliance with clinician
- Feel that after the first visit they are good/boosted their morale enough
- Not really interested in tx in the first place
What are Shea’s 8 goals of the clinical assessment?
- Effective engagement/data gathering process
- Collect info/form a valid database
- Develop evolving and compassionate understanding of pt
- Develop an assessment/tentative diagnosis
- Collaboratively identify problems and therapeutic goals
- Collaboratively develop tentative treatment
- Help the pt anxiety
- Instill hope and ensure the pt comes to the next appt.
Research suggest that the better the ______ the more _______ the data.
pt/clinician relationship
Valid
Autonomy
Respecting the pts right to make their own decisions. Includes informed consent, refusing medication, and maintaining confidentiality
Beneficence
act for the benefit of the patient, protect and defend the right of others, prevent harm, remove conditions that will cause harm, help persons with disabilities, and rescue persons in danger
Being empathetic and not letting personal interests/opinions get in the way
Non-malificence
“Do no harm”
Justice
fair, equitible and appropriate tx of persons
Distributive Justice
different valid principles of distributive justice. These are distribution to each person (i) an equal share, (ii) according to need, (iii) according to effort, (iv) according to contribution, (v) according to merit, and (vi) according to free-market exchanges.
Dialectical Principalism
an approach that addresses ethical dilemmas → method of laying out, prioritizing and balancing conflicting considerations
- The approach is designed to help one determine the most ethical action
Which ethics principle most favors advising the patient
about the possible consequences of providing information
that she is suicidal?
A. Autonomy
B. Nonmaleficence
C. Beneficence
D. Distributive justice
E. None of the above
A. Autonomy
The psychiatrist catches the smell of
alcohol on the patient’s breath as he talks, and although
there is no evidence of prior violence, the psychiatrist knows
that the patient has access to guns as a law enforcement
officer.
2.2 In light of the patient being a law enforcement officer,
which ethics principle is now weighted more heavily in favor
of interrupting the patient and advising him on the limits of
doctor-patient confidentiality?
A. Autonomy
B. Nonmaleficence
C. Distributive justice
D. Legal justice
E. None of the above
Nonmaleficence
What are the 3 types of practice as a PMHNP?
Full - w/o supervising physician
Reduced - perform some of the scope without a physician (restrictions in operating their own practices - Np will have to go through MD/practice to order certain tests & dx conditions)
Restricted - must work under supervision of physician - all tests and prescribing; NOT independent practitioners
What are the 2 certification options for PMHNP?
ANCC - American Nurses Credentialing Center
AANPCB - American Academy of Nurse Pracitioners Certification Board
HPI (History of Present Illness)
- provides foundational info thats gathered from the assessment
The present illness is a chronological description of the evolution of the symptoms of the current episode. Also, the account should include any other changes that have occurred during this same period in the patient’s interests, interpersonal relationships, behaviors, personal habits, and physical health.
What are the essential questions to be answered for HPI?
Symptoms
Severity (how much)
How Long?
Associated factors
Why is pt seeking help now?
What are the triggering factors?
*Also want to identify setting of HPI (can help provide additional info) & If any treatment has been received for the current episode, it should be defined in terms of who saw the patient and how often, what was done (e.g., psychotherapy or medication), and the specifics of the modality used.
Elements of the HPI for psychiatry:
Location: Regarding mental status, location could correspond to domain (e.g., mood, thought process, perception, etc.)
Quality: Descriptive language (e.g., forgetful, depressed, disorganized, hallucinating)
Severity: Language that relates to how bad the problem is (e.g., “8 out of 10,” controlled, uncontrolled)
Timing: Language that relates to when symptoms are experienced, such as in certain situations or time of day
Duration: Onset of symptoms and how long symptoms last
Context: Psychosocial factors related to the problem
Modifying factors: What brings on or relieves the problem?
Associated signs and symptoms: What else is happening? (e.g., loss of functions/drives, such as appetite, weight, libido, etc.)
What are the 4 areas of Review of Systems (ROS) from table 1.2 in Kaplans Review/Synopsis of Psychiatry
Mood - Depression/Mania/Mixed
Anxiety - GAD, Panic Disorders, OCD, PTSD, Social Anxiety symptoms, Simple Phobias
Psychosis - Hallucinations, Paranoia, Delusions, Patient’s perception:reality testing
Other (ADHD/Eating disorders)
Circumstancality
Overinclusion of trivial or irrelevant details that impede the sense of getting to the point.
Tangentiality
In response to a question, the patient gives a reply that is appropriate to the general topic without actually answering the question.
Neologism
The invention of new words or phrases or the use of conventional words in idiosyncratic ways.
Clang Associations
Thoughts are associated by the sound of words rather than by their meaning (e.g., through rhyming or assonance).
Derailment (synonymous with associations)
A breakdown in both the logical connection between ideas and the overall sense of goal directedness. The words make sentences, but the sentences do not make sense.
Flight of Ideas
A succession of multiple associations so that thoughts seem to move abruptly from idea to idea; often (but not invariably) expressed through rapid, pressured speech.
Perserveration
Repetition of out of context words, phrases, or ideas. Same things over and over and over
Thought Blocking
A sudden disruption of thought or a break in the flow of idea
What are the standard categories of the MSE?
Appearance
Behavior/Psychomotor activity
Attitude toward examiner
Affect & Mood
Speech & Thought
Perceptual disturbances
Orientation & Consciousness
Memory & Intelligence
Reliability, Judgment, and Insight
These are patients admitted to the hospital but who are free to leave at any time, even against medical advice.
Informal Voluntary Admission
These are patients admitted to the hospital who can leave the hospital only when discharged by the physician. Requests
to leave the hospital may be made by the patient, but they must be made in writing. During a specific period of time, the person is
evaluated by the physician and is either released or committed (
Formal Voluntary Admission
Patients not recognizing their need for hospitalization may be placed in the hospital to ensure the safety of themselves or
others or because they are considered gravely disabled. Before patients are admitted under this type of admission, they are evaluated by a
physician and, if deemed necessary, admitted for safety reasons. Patients are then evaluated by a second physician. Both physicians must
agree to keep a patient in the hospital. The judicial system may place someone in the hospital for treatment, but generally, patients are kept
in the hospital under the least restrictive measure to receive treatment. Patients do have the right to file a “writ of habeas corpus,” a legal
procedure to allow the courts to decide if a patient has been hospitalized without due process of law
Involuntary admission
Rapport
promotes a constructive therapeutic alliance;
Harmonious responsiveness of the physician to the patients and the patient to the physician
Empathy
the ability to recognize the immediate emotional perspective of another person while maintaining ones own perspective.
Understanding what the patient is thinking and feeling - psychiatrist can put him/herself in the pt’s place while still maintaining objectivity.
A large majority of empathic response in an interview are nonverbal
Must maintain objectivity
Scouting period
pts narrative - approximately 5-7 (or 6-9 minutes) in the beginning of the interview where the clinician assessess
1. pts conscious view of his/her problems
2. pts mental status
3. clinicians conceptualization of the pts prolem
4.quick evaluation of interview process itself
Ex. of Empathetic intervention
“it sounds like everything seemed to be collapsing around you”
“That must have been difficult foryou”
How do you assess ego functioning?
The assessment of ego functioning yields important information about a patient’s sense of self and the degree to which he or she has consolidated a core identity.
Want to use the Observer rated Ego Functioning too: How do you deal with strong feelings? How would you describe yourself? What kind of person is your mother? What do you think is the cause of your problems?
Capitalize on ego strengths rather than weaknesses
Ego strength
Ego strength is the capacity for effective personal functioning (adaptability, resourcefulness, self-efficacy, self esteem, interpersonal effectiveness, life satisfaction etc.)
How do you assess affective development
Ask about the experience of the person’s feelings.
Ex. Are you generally able to recognize how you feel at a given time? How would you describe your feelings right now?
Objectivity
ignoring your personal judments. provide non biased reitieration of the facts
They can also use the scientific method
Resistance
processes, conscious or unconscious that interfere with the therapeutic objectives of treatment. It can inhibit change and shows there is an opportunity for insight
Pt often unaware of the impact of these feelings, thinking, or behaviors, which may take many different forms, including exaggerated emotional responses, intellectualization, generalization, missed appts, or acting out behaviors.
Repression
unconscious processes that keeps issues or feelings out of awareness.
Defense mechanism and the emotion can resurface in other ways
To help undo - use insight - oriented psychotherapy to help unconscious feelings come to awareness (avoid doing this in first session; wait for subsequent sessions)
What is the focus of the Person-centered approach?
The focus should be on understanding the patient and enabling the patient to tell his or her story.
The patient should also be explicitly encouraged to identify his or her goals/aspirations in own words in order to allow the treatment plan to be based on the patient’s goals and not the psychiatrist’s goals.
Focus on the pts strengths and deficits “Tell me what your greatest assets are?”
Provide support through rapport and non-judgment
HIPAA
1996- rules developed by the Dept of Health and Human services protecting the transmission and confidentiality of pt information
Who is responsible for making sure the Privacy Rule is enforced?
The OFFICE OF CIVIL RIGHTS at Dept of Human Health Services (HHS) is responsible for making sure the Privacy Rule is enforced
What is the privacy rule?
Administered by the Office of Civil Rights it protects the confidentiality of patient information = pt medical information belongs to the patient and the patient has the right to access it, except for psychotherapy notes which are deemed as property of the psychotherapist who wrote them
How is the Review of Systems Organized? (ROS)
Mood
Anxiety
Psychosis
Other
MENTAL STATUS EXAM (MSE)
is a systematic way of describing a patient’s mental state at the time you were doing a psychiatric assessment. An observant clinician can do a comprehensive mental status exam that helps guide them towards a diagnosis.
WHAT are the components of the MSE
Appearance/Behavior
Speech
Emotions (mood/Affect)
Perception - (disturbances - hallucinations etc)
Thought processes & Content (how are the thoughts formulated - organized, linear etc & how they are - suicidality, homicidality, delusions)
Insight & Judgment
Cognition (A&O, concentration, memory, abstract reasoning)
Purpose of family history
Exploration of psychiatric illnesses in blood related family
helps define risk factors for disorders that are heritable
Can also gain better insight into medications that worked and didn’t work
Reliability
CONSISTENCY OR REPEATABILITY of ratings (an instrument is more likely to be reliable if the instructions and questions are clearly and simply worded, and the format is easy to understand and score)
3 ways to test:
Interrater
Test-Retest
Internal Consistency
Validity
TRUTH: can the instrument make the correct classifications (categorical context) or is the instrument accurate/true state of nature (continuous context)
Does the scale measure what it is supposed to measure
What are two types of measurements of validity
Sensitivity
Specificity
Sensititivy
Does the scale detect the symptoms of the disease
Specificity
whether or not the scale only detects for that SPECIFIC condition & not another
Who determines the scope of practice of the NP?
American Psychiatric Nurses Association (APNA)
12 core competencies of NP
Mgmt of health status
Maintain nurse pt relationship
Teaching
Professional Role
Mng + negotiate healthcare delivery sytems
Monitoring quality
Providing culturally sensitive care
Specialty specific
Health promotion, disease, prevention + tx
Diagnose health status
Plan of care/tx
