psychosocial assessment Flashcards
BASIC INTERVIEW STAGES
- OPENING /INTRODUCTION
- sets the tone - BODY / DEVELOPMENT
- patient responds to questions
- data collected - CLOSING
- termination of the interview
- pt or nurse ends it
OPENING /INTRODUCTION
- establish rapport
- explain purpose and nature of interview
may I sit down for about 10 min to talk about what brought you into the hospital
feel free to day if there is anything you don’t want to talk about
BODY/DEVELOPMENT
types of interview questions
closed- answer is restricted to few words
open- invitation to explore thoughts / feelings
neutral- freedom to answer without pressure
leading- limits accuracy of response
WHAT TO DO DURING INTERVIEW
-listen attentively
-use simple 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
what to do during closing
- offer to answer questions
- offer clear conclusion
- thank the patient
- express concern for future welfare
- plan for next meeting
- provide a summary
CONSIDERATIONS
- effective nurse communication
- holistic approach
- interview environment
- patients developmental level
- patient emotional factors
- patient family factors
- patient culture
PSYCHOSOCIAL ASSESSMENT GOAL
to understand the patient
evaluates:
- mental health and illness
- social well being
- perception of self
- ability to function in community
- multiple domains of mental status
COMPONENTS OF PSYCHOSOCIAL ASSESSMNENT
identify patient chief complaint history of present illness psychiatric history med/surg history medication list alcohol and drug use family history developmental history social history violence risk mental status exam
SOCIAL HISTORY COMPNENTS
social relationships living situation significant life events employment education legal spiritual cultural financial situation coping skills interest /hobbies
OBTAINING MILITARY HISTORY
general question
would it be ok is I ask about your military experience
if answer is affirmative
- how has military service affected you
- did you see combat , enemy fire , or casualties
- were you or a buddy wounded , injured or hospitalized
- do you have a service connected condition
MENTAL STATUS EXAM
analoguous to the physical exam assessment of brain function -mental function -emotions -behaviors
some aspects obtained by observation
some aspects obtained by direct questioning
MENTAL STATUS EXAM COMPENENTS
- general appearance
- motor activity
- speech /communication
- emotional state
- though content
- thought process
- perceptual disturbances
- cognition
- abstract reasoning
- insight and judgment
GENERAL APPERANCES
- apparent age
- dress
- hygiene/grooming
- posture
- facial expression
- eye contact
- pupils
- general state of health /nutrition
- acute distress
MOTOR ACTIVITY
rate of movement
- slowed
- agitated
Gait
- freedom
- pacing
- posture
Unusual movements
- tics
- tremors
- jittriness
- hand wringing
- muscle spasm
- lip smacking/tongue protrusion
- unable to remain still
SPEECH/COMMUNICATION
Communication
- process of content being expressed
- resistant
- disorganized
- negative
- requires prompting
Speech
- how content articulated
- fluency
- rate
- amount
- tone
- volume
- repetition
EMOTIONAL STATE
MOOD subjective emotional state -sad -angry -guilty -anxious
AFFECT
- outward expression of emotional state
- flat
- blunted/constricted
- tearful
- euthymic
TYPES OF THOUGHT
phobias hypochondriasis ideas of reference magical thinking obsession/preoccupations thought insertion thought broadcasting suicidal ideation homicidal ideation delusions
TYPES OF DELUSIONS
grandiose persecutory jealousy religious somatic ideas of reference thought insertion thought broadcasting
THOUGHT PROCESS
-description of how thoughts arw formulated organized and expressed
flight of ideas tangential circumstantial neologisms looseness of association word salad clanging thought blocking poverty of speech
PERCEPTUAL DISTURBANCES
Hallucinations
- percetions in the absence of stimuli to account for them
- may involve any of 5 senses
- auditory most common
ILLUSIONS
- misperception of stimuli
- ex mistaking wind for a voice
DEPERSONALIZATION
- feeling detachment from oneself
- ex looking down and seeing oneself
DEREALIZATION
feeling environment has changed
-ex- feeling a barrier between oneself and the world
COGNITION
-alertness
-orientation
-memory
immediate
recent
long term
calculations
concentration/attention
visuospatel ability
abstract reasoning
INSIGHT
patient’s undertsnading 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
JUDGEMENT
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
FUCNTIONAL ABILITY
self care
socialization
apetite
sleep
