Week 2 - MSE and risk assessment Flashcards
Identify and describe the components of an MSE
Appearance
* weight
* grooming
* dress
* expression
* wounds, scars, tattoos
Behaviour
* walk
* combativeness
* guestures, twitches
* activity (overactivity, compulsion)
* catatonia
Mood
* how are you today/how are you feeling
* mood swings
* is their mood appropriate
Affect
* how the consumer appears/comes across
* is their affect appropriate
Thought form and content
* content of thought (poverty, obsession, compulsion)
* delusions (type and explanation)
* phobias
* thought form ( how they present their thoughts through speech)
* disturbances of speech
Speech
* rate
* tone/quality
* quantity
* comprehension
* intelligibility
* volume
Orientation
* time, place, person
Perception
* hallucinations (type and explanation)
* disassociation
Insight
* denial of disorder
* impaired insight
* true insight
Judgement
* critical or impaired
Identify and describe the components of a risk assessment
Risk to self
* suicide or self harm
* self neglect
* substance misuse
* reputation
* medication non-adherance which leads to mental state deterioration
* financial/work/education loss
* risk taking behaviour
* legal issues
Risk to others
* threatening behaviour
* physical violence
* verbal/emotional abuse
* stalking
* damage to property
* not able to care for dependants
Risk by others
* assault
* sexual/emotional/financial exploitation or abuse
* verbal abuse
Static risks - risks that are fixed or historical in nature. Cannot be changed. Part of the person due to demographic, biological, psychological or social reasons
Dynamic risks - risks that change in duration and intensity dependent on circumstances. practitioners can influence and mitigate these risk factors through
* psychoeducation
* treatment
* service provision
* early intervention
Categorised by environmental, mental, physical, and psychosocial
When should an MSE be completed
- admission and discharge
- transfer
- before taking leave
- upon comprehensive mental health assessment
- each shift
- change in presentation
- as per hospital policy
When should a risk assessment be completed
- admission or discharge
- transfer
- upon comprehensive mental health assessment
- before taking leave
- each shift
- each time there is a change in condition
- as per hospital policy
Sexual disinhibition assessment (Bipolar)
Aim of the mental health assessment
To bring together all relevant details regarding the consumer to formulate clear treatment goals and plans
What are the components of a mental health assessment
Demographics
* age, living, children, partner
Presenting symptoms
Previous psychiatric history
* diagnoses, admissions, contact with services
Risk assessment
Mental state examination
Current and previous medications
Full medical history and substance use history
Family history - medical and social
Developmental history
* Milestones, schooling, friendships, personality traits
Occupational history
Forensic history - legal, incarceration
Cultural issues and considerations
Goals for treatment
Where can you source information to complete a mental health assessment?
- consumer
- family and friends
- case manager
- previous admission notes (inpatient and ED)
- GP
- psychologist
- past medical notes/imaging
- forensic and legal documentation
Provisional vs Formal diagnoses
Provisional: clinician’s educated guess on the most likely diagnosis while they confirm/reassess
* requires assessment o vertime
* needs to differentiate between drug related and medical conditions
* need to specify the primary disorder
* differentiate between disorders with similar symptoms
Formal diagnosis: a diagnosis which has been substantiated or confirmed
What is the purpose of an MSE
- Allows nurse to formulate nursing diagnoses to plan care
- provides a baseline of symptoms for identifying and managing mental ill ess
- is used to inform a formal diagnosis
Define positive risk taking and dignity of risk
Positive risk taking -when a consumer decides to take a risky choice in the name of personal development, growth, or life improvement. Should always be done in a supportive environment
Dignity of risk - gives poeple the opportunity to learn by making their own decisions. Refers to the maintenence of dignity and autonomy which is afforded in a person independently deciding to take a step which involves risk.
Nursing management for de-escelation
- Respect personal space - do not provoke
- Offer choice and optimism - be concise
- Establish verbal communication and set clear limits
- Actively listen to identify the consumers wants and feelings
- Agree, or agree to disagree
- debrief the consumer and staff members
How to recognise signs of deterioration in a person’s mental state?
* keep deterioration in the back of your head
* complete regular screening (MSE and risk) to identify issues which could impact on deterioration and to track the pattern over admission
* Reassess for deterioration at any point signs, symptoms or mental state change
* mitigate any factors of care which might contribute to deterioration
* document all findings
* once escalated, address with urgency to prevent further deterioration
How to escalate care?
* ecalate to senior staff as soon as abnormal change in mental state is detected
* patient and support persons (if they are able to) should be debriefed and kept updated
* nurse should take detailed clinical notes
How to respond to signs of deterioration?
* follow hospital policy
**How to respond to signs of deterioration? **
* escalate care and carry out immediate intervention as per hosptial policy to prevent further deterioration
* collaborate with interdisciplinary team
* work based on the agreed goals of care and consumers goals of recovery
* involve the consumer as much as possible
* de-escelate, relax, sensory modulate, reassess, etc
* assess response to interventions
* provide private, low-stimulus environments
* debrief all involved and notes taken
Strategies to promote safety for the person, staff, and other people in the clinical environment
