The Nursing Process in Psychiatric/Mental Health Nursing Flashcards
Assessment & Documentation
Key to contributing to establishment of psychiatric diagnosis
Proper diagnosis leads to effective treatment
Nursing input is more crucial in the diagnostic processin psychiatry than medical and surgical settings
Medical-Surgical Diagnosis
MD physical exam
Tests such as EKG and X-ray
Labs – blood and body fluid analysis
RN assessment minor in diagnosis
RN use of the nursing process to enhance med-surg treatment via nursing interventions/nursing process
Psychiatric Diagnosis
MD physical exam to rule out medical conditions
Mental status exam(MSE) by MD and Nursing
- observations of patient behavior in the environment over time
- interactions with patient over time
Some labs
Some psychological tests if needed for Differential Diagnosis
Establishes diagnosis and yields most effective treatment
Nursing Observation and Documentation
- Nurses do parts or all of the MSE
- Nurses observe patient behavior and interactions
- Nurses document response to treatment
- MD re-interview also establishes response to treatment
- Nurses also use nursing process to provide independent care
- Psychiatric DX and care is multidisciplinary
Holistic -Biopsychosocial
- Hx of present illness, Psychiatric Hx, Substance use Hx, Coping skills – PSYCHOLOGICAL
- Medical Hx – PHYSICAL
- Family Hx and Developmental Hx – PSYCHOLOGICAL, PHYSICAL, SOCIAL
- Social, Occupational/Educational Hx, Culture – SOCIAL
- Spirituality - SPIRITUAL
Mental Status Exam - Elements
- Appearance
- Behavior/Activity
- Speech
- Attitude
- Mood & Affect
- Thought Process
- Thought Content
- Perceptual Disturbance
- Memory/Cognition
- Insight & Judgement
Appearance
- Grooming /dress___________________
- Hygiene__________________________
- Eye Contact_______________________
- Posture___________________________
- Identifying features (scars,tatoos)______
- Appearance versus stated age__________
- Overall appearance__________________
BEHAVIOR/ACTIVITY
Hyperactive___, Agitated___, Psychomotor retardation___, Calm___, Tremors___, Tics___, Unusual movements/gestures___, Catatonia___, Akathisia___, Rigidity___, Facial movements(jaw/lip smacking)___, Other_______
SPEECH
Slow/rapid___, Pressured___, Tone___, Volume(loud/soft)___, Fluency(mute, hesitation, latency of response)___
Attitude
Cooperative___, Uncooperative____ Warm and friendly____, Distant___ Suspicious___, Guarded___, Aggressive___, Hostile___, Combative___ Apathetic___, Aloof___ Other__________________
MOOD AND AFFECT
MOOD – (general feeling ) Observe and listen
- Elated___, Sad___, Depressed___, Irritable___, Anxious___, Fearful___, Guilty___, Worried___, Angry___, Hopeless___, Labile___, Mixed(anxious and Depressed)
AFFECT – facial expression
- Flat___, Blunted or diminished___,
- Full range___,
- Inappropriate/incongruent(sad and smiling laughing) e.g.. Smiling at a funeral of a loved one when time to be serious. Facial expression does not fit with the topic being discussed
THOUGHT PROCESS
- Cognition – How the patient thinks, thinking processes
- Concrete thinking___, Circumstantiality___, Tangentiality___, Loose associations___, Flight of ideas___, Perserveration___, Blocking___, Derailment___,
- (Echolalia, Clang associations, Word salad – not seen often)
- Other___________
Thought Content
- What the patient says
- Delusions
- (Gradiose / persecutory/reference/ somatic)___,Homocidal - to whom?____, Suicidal – describe____, Obsessions___, Paranoia___, Phobias___, Magical thinking___, Poverty of speech___, Other__________
PERCEPTUAL DISTURBANCE
- Visual hallucinations___, Auditory___
- commenting___, discussion___, commanding___, loud___, soft___, other________ Other hallucination (Olfactory / tactile) Illusions___, Depersonalization___, Other_________
MEMORY/COGNITION
- Orientation___,
- Memory (Recent/remote/confabulation)____,
- Level of alertness (Level of consciousness)___