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Psych Exam 1 > Psychosocial Assessment > Flashcards

Psychosocial Assessment Flashcards

1
Q

Basic interview:

Stages

A 
1. OPENING/INTRODUCTION
  • SETS THE TONE
2. BODY/DEVELOPMENT
  • PATIENT RESPONDS TO QUESTIONS 
3. CLOSING
  • TERMINATION OF THE INTERVIEW
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2
Q

Basic interview:

Opening/Introduction

A

• ESTABLISH RAPPORT
• EXPLAIN PURPOSE AND NATURE OF INTERVIEW
• “MAY I SIT DOWN FOR ABOUT 10 MINUTES TO
TALK ABOUT WHAT BROUGHT YOU INTO THE HOSPITAL?”
• “ FEEL FREE TO SAY IF THERE IS ANYTHING YOU DON’T WANT TO TALK ABOUT.”

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3
Q

Basic Interview:
Body/Development
Types of interview questions

A 
• CLOSED: ANSWER IS RESTRICTED TO FEW WORDS
• OPEN-ENDED: INVITATION TO EXPLORE
THOUGHTS/FEELINGS
• NEUTRAL: FREEDOM TO ANSWER WITHOUT
PRESSURE
• LEADING: LIMITS ACCURACY OF RESPONSE
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4
Q

Basic Interview:

Body/Development

A
  • LISTEN ATTENTIVELY
  • USE SIMPLY LANGUAGE
  • CLARIFY POINTS NOT UNDERSTOOD
  • QUESTION IN LOGICAL SEQUENCE
  • ASK ONE QUESTION AT A TIME
  • DO NOT IMPOSE OWN VALUES
  • AVOID USING PERSONAL EXAMPLES
  • CONVEY RESPECT AND INTEREST
  • BE AWARE OF BODY LANGUAGE
  • BE AWARE OF VOICE
  • SIT AT EVEN LEVEL
  • USE SILENCE TO ALLOW PATIENT TO ORGANIZE THOUGHTS
  • USE EYE CONTACT AND BE UNHURRIED
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5
Q

Basic Interview:

Closing

A
  • OFFER TO ANSWER QUESTIONS
  • OFFER CLEAR CONCLUSION
  • THANK THE PATIENT
  • EXPRESS CONCERN FOR FUTURE WELFARE
  • PLAN FOR NEXT MEETING
  • PROVIDE A SUMMARY
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6
Q

Considerations to take when doing a psychosocial assessment

A
  • EFFECTIVE NURSE COMMUNICATION • HOLISTIC APPROACH
  • INTERVIEW ENVIRONMENT
  • PATIENT’S DEVELOPMENTAL LEVEL
  • PATIENT EMOTIONAL FACTORS • PATIENT FAMILY FACTORS
  • PATIENT CULTURE
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7
Q

Psychosocial assessment goal:

A

To understand patient

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8
Q

Psychosocial assessment evaluates:

A
  • MENTAL HEALTH & ILLNESS
  • SOCIAL WELL-BEING
  • PERCEPTION OF SELF
  • ABILITY TO FUNCTION IN COMMUNITY
  • MULTIPLE DOMAINS OF MENTAL STATUS
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9
Q

Components of psychosocial assessment

A
  • IDENTIFY PATIENT
  • CHIEF COMPLAINT
  • HISTORY OF PRESENT ILLNESS
  • PSYCHIATRIC HISTORY
  • MED/SURG HISTORY
  • MEDICATION LIST
  • ALCOHOL & DRUG USE
  • FAMILY HISTORY
  • DEVELOPMENTAL HISTORY
  • SOCIAL HISTORY
  • VIOLENCE RISK
  • MENTAL STATUS EXAM
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10
Q

Social hx components

A
  • SOCIAL RELATIONSHIPS
  • LIVING SITUATION
  • SIGNIFICANT LIFE EVENTS
  • EMPLOYMENT
  • EDUCATION
  • LEGAL
  • SPIRITUAL
  • CULTURAL
  • FINANCIAL SITUATION
  • COPING SKILLS
  • INTERESTS/HOBBIES
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11
Q

How to obtain military hx?

A

GENERAL QUESTION
• “WOULD IT BE OKAY IF I ASKED ABOUT YOUR MILITARY EXPERIENCE?”

IF ANSWERS IN AFFIRMATIVE:
• “HOW HAS MILITARY SERVICE AFFECTED YOU?
• “DID YOU SEE COMBAT, ENEMY FIRE, OR CAUSALITIES?”
• “WERE YOU OR A BUDDY WOUNDED, INJURED, OR
HOSPITALIZED?”
• “DO YOU HAVE A SERVICE-CONNECTED CONDITION?”

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12
Q

Questions to ask for:

self-harm

A
  • Have you had thoughts of hurting yourself?

- Do you ever cut or injure/harm yourself?

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13
Q

Questions to ask for:

Suicide risk

A
  • Have you had thoughts of hurting yourself?
  • Can these thoughts of harm be managed?
  • Do you have a plan to commit suicide? What is the plan?
  • Do you intend to carry out the plan?
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14
Q

Questions to ask for:

Homicide risk

A
  • Do you have thoughts of harming others?
  • Who is the target?
  • Is there intent to carry out the plan?
  • Do you have a means to carry out a plan to harm others?
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15
Q

Questions to ask for:

Abuse

A

• Are you in a relationship with someone who physically harms or threatens you?

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16
Q

Mental Status Exam components:

A
  • GENERAL APPEARANCE
  • MOTOR ACTIVITY
  • SPEECH/COMMUNICATION
  • EMOTIONAL STATE
  • THOUGHT CONTENT
  • THOUGHT PROCESSES
  • PERCEPTUAL DISTURBANCES
  • COGNITION
  • ABSTRACT REASONING
  • INSIGHT & JUDGEMENT
17
Q

Mental Status Exam:

General appearance

A
  • APPARENT AGE
  • DRESS
  • HYGIENE/GROOMING
  • POSTURE
  • FACIAL EXPRESSION
  • EYE CONTACT
  • PUPILS
  • GENERAL STATE OF HEALTH/NUTRITION
  • ACUTE DISTRESS
18
Q

Mental Status Exam:

Motor activity

A 
RATE OF MOVEMENT
  • SLOWED (BRADYKINESIA)   
  • AGITATED (HYPERKINESIA)
GAIT
  • FREEDOM
  • PACING 
  • POSTURE
UNUSUAL MOVEMENTS 
  • TICS
  • TREMORS
  • JITTERINESS
  • HAND WRINGING 
  • MUSCLE SPASMS
  • LIP SMACKING
  • UNABLE TO REMAIN STILL (AKATHISIA)
19
Q

Mental Status Exam:

Speech

A 
HOW CONTENT ARTICULATED
  • FLUENCY 
  • RATE
  • AMOUNT 
  • TONE
  • VOLUME
  • REPETITION
20
Q

Mental Status Exam:

Emotional state: Mood

A 
SUBJECTIVE EMOTIONAL STATE
  • “SAD”
  • “ANGRY”
  • “GUILTY”
  • “ANXIOUS”
21
Q

Mental Status Exam:
Thought content:
Types of thoughts

A 
• PHOBIAS
• HYPOCHONDRIASIS
• IDEAS OF REFERENCE
• MAGICAL THINKING
• OBSESSIONS/ PREOCCUPATIONS
• THOUGHT INSERTION
• THOUGHT
BROADCASTING
• SUICIDAL IDEATION
• HOMICIDAL IDEATION 
• DELUSIONS
22
Q

Mental Status Exam:

Thought process

A 
DESCRIPTION OF HOW THOUGHTS ARE FORMULATED, ORGANIZED & EXPRESSED
  • FLIGHT OF IDEAS 
  • TANGENTIAL
  • CIRCUMSTANTIAL 
  • NEOLOGISMS
  • LOOSENESS OF ASSOCIATION 
  • WORD SALAD
  • CLANGING
  • THOUGHT BLOCKING
  • POVERTY OF SPEECH
23
Q

Mental Status Exam:

Perceptual disturbances

A 
HALLUCINATIONS
  • PERCEPTIONS IN THE ABSENCE OF STIMULI TO
ACCOUNT FOR THEM
• MAY INVOLVE ANY OF 5 SENSES
  - AUDITORY MOST COMMON
      • COMMAND VS NON-COMMAND

• “DO YOU HEAR VOICES WHEN NO ONE IS AROUND?”

ILLUSIONS
• MISPERCEPTION OF STIMULI
• EX- MISTAKING WIND FOR A VOICE

DEPERSONALIZATION
• FEELING DETACHMENT FROM ONESELF
• EX- LOOKING DOWN AND SEEING ONESELF

DEREALIZATION
• FEEING ENVIRONMENT HAS CHANGED
• EX- FEELING A BARRIER BETWEEN ONESELF AND THE WORLD

24
Q

Mental Status Exam:

Cognition

A 
• ALERTNESS
• ORIENTATION 
• MEMORY
  - IMMEDIATE
  - RECENT
  - LONG-TERM
• CONCENTRATION/ ATTENTION
• VISUOSPATIAL ABILITY 
• ABSTRACT REASONING
• CALCULATIONS
25
Q

Mental Status Exam:

Insight

A

PATIENT’S UNDERSTANDING OF:
• OWN FEELINGS
• HOW PRESENTING AND FUNCTIONING
• POTENTIAL CAUSES OF PSYCHIATRIC SYMPTOMS

REALITY TESTING WITH PSYCHOSIS
• “I KNOW THERE ARE NOT LITTLE MEN IN MY HOME, BUT I CAN SEE THEM AND HEAR THEIR VOICES”

26
Q

Mental Status Exam: Judgement

A

• CAPACITY TO MAKE HEALTHY DECISIONS
- ALSO TO ACT ON HEALTHY DECISIONS
• MAY OR MAY NOT CORRELATE WITH LEVEL OF INSIGHT
**• CAN BE TESTED WITH HYPOTHETICAL EXAMPLES
• RECOMMENDED TO USE REAL PATIENT SITUATIONS

27
Q

Mental Status Exam:

Functional ability

A
  • SELF-CARE
  • SOCIALIZATION
  • APPETITE
  • SLEEP
28
Q

Mental Status Exam:

Communication

A 
PROCESS OF CONTENT BEING EXPRESSED
  • RESISTANT
  • DISORGANIZED
  • NEGATIVE
  • REQUIRES PROMPTING
29
Q

Mental Status Exam:

Emotional state: Affect

A 
OUTWARD EXPRESSION OF EMOTIONAL STATE
  • FLAT
  • BLUNTED/CONSTRICTED 
  • TEARFUL
  • EUTHYMIC
30
Q

Mental Status Exam:
Thought content:
Types of delusions

A
  • GRANDIOSE
  • PERSECUTORY
  • JEALOUSY
  • RELIGIOUS
  • SOMATIC
  • IDEAS OF REFERENCE
  • THOUGHT INSERTION
  • THOUGHT BROADCASTING

Psych Exam 1 (5 decks)

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