week 2 - assessment in the context of mental health

Question 1

comprehensive vs focused assessment (main points) & thins to consider when choosing between them

Answer 1

comprehensive
- complete health history
- physical examination

focused
- specific information about a need, problem, or situation

consider the context of the assessment & goals of the assessment
- immediate needs of the client in an emergency
- how to build rapport and trust to get a quality assessment done

Question 2

components of comprehensive assessment (4)

Answer 2

1. primary reason for seeking care
   - understand clients perception and insight into existing problem & goal
   - ideally client is the source of info, other sources? (POA, chart, SDM)
2. health history and current health status
   - mental & physical hx, biological, social, spiritual, psychological components
3. lab values and investigations
   - psychiatric meds, blood work
4. psychosocial

Question 3

what is the mental status exam

Answer 3

systemic focused assessment of mental status
- not to be confused with MMSE (for cognitive impairment)

Question 4

components of mental status exam (a big smart monkey thinks things, plays cool, is joyful)

Answer 4

appearance
behaviour (motor activity)
speech
mood and affect
thought content
thought process
perception
cognition and sensorium
insight
judgement

Question 5

MSE - documentation (how should you format it)

Answer 5

client is/demonstrates/presents X as evidenced by
client is (assessment findings) as evidenced by (observed)

ex: client presented as restless as evidenced by frequent position changes, fidgeting, and consistent playing with their hair

Question 6

mood & affect (difference)

Answer 6

mood (subjective)
- how does the client REPORT feeling

affect (objective)
- how does the client APPEAR they are feeling

Question 7

what does labile mean

Answer 7

rapid shifting of emotional response

Question 8

thought content - what are obsessions, ruminations, ideas of reference, delusions

Answer 8

obsessions
- thoughts, images, or impulses that occur over and over again and feel out of the persons control
ruminations
- concepts or life events that the client is thinking about repeatedly
ideas of reference
- false beliefs that random or irrelevent occurrences in the world directly relate to a person
delusions
- false belief kept despite supportive evidence that they are not reality based

Question 9

perception - hallucinations vs illusions

Answer 9

hallucinations
- sensory information that does not exist in reality
- perceptions that occur WITHOUT any external stimulus

illusions
- misrepresentation of REAL external stimuli

Question 10

insight & judgement - importance of assessing this, what are they

Answer 10

assess clients capacity to recognize lived experiences and make sound, reasonable decisions

insight
- awareness of illness or symptoms, the capacity to appreciate the nature of the situation

judgement
- ability to solve problems and make appropriate decisions, awareness of limitations, consequences of actions

Question 11

important factors in reliability of information

Answer 11

• source
• setting
• therapeutic relationship
• secondary/subsequent validation