Week 3 Flashcards
Why is the Comprehensive Psychiatric assessment important?
- Performing a holistic, comprehensive and accurate assessment is a core skill of the mental health nurse
- The assessment process is dynamic and evolving in response to the client’s presentation, dependent on the venue and the ability of the clinician to engage the client.
- Assessments can be classified as formal/structured or informal, incorporating specialist assessment tools.
What is the purpose of the comprehensive assessment?
- Communicate, identify and clarify the client’s health issues?
- Assess the client’s physical health status and exclude organic causes
- Identify personal/family and social supports that can be utilized in collaborative care and treatment planning provides the client/carers the opportunity to express their distress/concern while engaging in the assessment process.
What is the outcome of the comprehensive assessment?
Upon completion of the comprehensive assessment a ‘provisional’ diagnosis can be established based on the data gathered with reference to the appropriate criteria set out in DSM-4-TR.
What does the comprehensive assessment consist of?
Reason for referral; Current living arrangements; presenting problem; history of presenting problem; family history; personal history; education; occupational; relationships/sexual; children and parenting; forensic history; previous or current illness; personality; safety and risks; and substance use &/or misuse.
What does the reason for refusal in the comprehensive psychiatric assessment consist of?
Who referred the client and Why? Referrers can be self, family, friends, GP’s, private health professionals or authorities (police, courts, employers).
What does the presenting problem part of the comprehensive psychiatric assessment consist of?
What are the events that led to the clients presentation? The subjective explanation, experiences and emotional factors will give the MHN opportunities to by completed MSE and screening tools.
What does the History of Presenting Problem consist of in the comprehensive psychiatric assessment?
The duration and global impact of mental health issues will be explored and chronological order will be established. Previous history, interventions, and treatments will be examined and efficacy of these will be established. Past professional treatments will be explored.
What does the family history consist of in the comprehensive psychiatric assessment?
Is there a family history of mental illness, suicide, substance and or ETCH abuse or medical conditions? Events of trauma such as war, long hospitalisations, divorce, infedelity, familial conflicts and estrangements are examples. Parental and sibling relationship factors need exploring also. Genograms should detail and highlight these factors.
What does personal history consist of in the comprehensiveul psychiatric assessment?
Developmental - Were there any known delays in walking, talking, or socializing? Presence of seperation issues and earliest memories of the client. Did they attend pre-school? were there any developmental delays, especially for younger clients?
What does the education consist of in the comprehensive psychiatric assessment?
Primary and Secondary schooling. Highest academic achievement. Peer group, isolation and possibility of bullying. Ability to make and keep friendships, was there a history of bullying. Attendance and or behavioral issues. Suspensions, expulsions or failed subjects, frequent change of school.
What does the Occupational consist of in the comprehensive psyschiatric assessment?
What is the client’s current occupation and length of job? Blue or white collar Job? Recent changes of position or colleague and/or employer conflicts. Shift work and impact on wake/sleep cycles?Have there been multiple Job changes, if so Why?
What does the relationships/sexual component consist of in the comprehensive psychiatric assessment?
Is the client currently in a relationship? Are there past sexual abuses/s, rape/s, De-facto, marriage/s (open and closed), & brief sexual liaisons? Are safe sex practices used? Are there previous STI’s or associated conditions? What sexual orientation does the client have? Manic phase can have multiple sexual partners.
What is required when conducting an MSE?
- Accuracy and clarity of the MSE depends on the interpersonal facets, attitude, experience, observational and interviewing skills of the nurse
- When inconguruence exists, the nurse can descretley observe the client to validate their subjective Vs Objective presentation.
- Interviews can conducted in a variety of settings. The preference is for areas that ensure optimal privacy and dignity.
- Confidentiality should be maintained and where possible consent obtained by the client. Dependent on the risk issues and in accordance with relevant MHA protocols, necessary information can be given to given persons perceived to be at harm from the client.
What are the components of the MSE?
perception; Affect/Mood; Motor activity/behavior; Speech/Language; general appearance; Orientation; Thought Process/Content; Judgement; Intellectual Functioning; Memory; Insight
What is the Acronym for the MSE?
PAMSGOTJIMI
P- Perception A- Affect/mood M- Motor activity/behaviour S- Speech/Language G- General appearance O- Orientation T- Thought process/content J- Judgement I- Intellectual functioning M- Memory I - Insight
what does the general Appearance component of the MSE assess
- Physical features to include are: gender, ethinicity, height, build, complexion
- General physical condition and nutritional status
- Posture
- Gait
- Mannerisms and/or Tics
- Any physical deformities and abnormalities, including tatoos, scars and piercings
- Grooming/Dress
- Facial expression
- Eyes - clear, bloodshot or ‘glazed’ N.B - dilated pupils are sometimes associated with drug intoxication, pupil constriction - narcotic addiction.
What does the Motor Activity/Behaviour compluonent of the MSE assess?
- Co-operative/Unco-operative with interview process
- Sociable and easy to engage or guarded and suspicious, hyper vigilant
- Consistent or unpredictable displays of behaviours
- Spontaneous in their interactions and displaying initiative or passive with minimal responses
- Eye contact (take culture into consideration)
- Restless, pacing, psycho motor agitation or retardation, hand wringing, bizarre movements or motor or vocal tics
- Anxious with associated tremor
- Over familiar and inappropriate behaviour opposed to withdrawn
- Hostile, threatening or intimidatory behaviour - intruding into personal space.
What does the speech component of the MSE assess?
The major components of speech are as follows
- Rate - slow, rapid, fluent or normal
- Volume - Loud, soft, incoherent, coherent or normal
- Tone - Monotonous, clear, accent, normal
The client may be articulate with a broad vocabulary or simplistic.
During an MSE observe the following:
- Pressure of speech - fast, hard to interrupt and understand, difficult to interrupt and can be loud
- Poverty of speech - Depressed
- Mutism - Total absence of speech
- Stuttering - Vocal tics
- Slurred speech
- Whispered
What does the Mood/Affect component of the MSE assess?
Mood describes the internal feeling or emotion, which often influences behaviour and the individuals perception of the world. The clients self report (subjective) of their mood is an essential part of the MSE
Affect refers to the external emotional response of the client. The interviewers (objective) determines what is the observed emotional response of the client
Both aspects provide clarity in diagnosing the client. This leads to the client displaying Congruent or incongruant mood and affect.
- Describe and note whether the emotional response is appropriate given the subject being discussed.
- some terms of mood include: euthymic, depressed, happy, sad, anxious, angry
- Some terms of affect include: reactive, restricted, blunted, and flat. Other decriptive terms are: dysthymic, labile, inappropriate, elated, euphoric, perplexed and fatuous.
What does the Perception component of the MSE assess?
Hallucinations - are defined as false sensory perceptions in which the individual sees, hears, smells, senses, or tastes something that other people do not.
Hallucinations can occur in the absence of psychosis. They can occur when falling asleep - hypogogic. they can occur when awakening - hypopompic.
The different types of hallucinations are
Auditory - non verbal or verbal (most common type of perceptual disturbance)
Visual - sees images, objects or persons
Olfactory - smells non existant things
Gustatory - centred on the sense of taste
tactile - relates to touch or skin surface sensations.
What are other types of perceptual disturbances other than hallucinations?
Derealisation; depersonalisation; heightened perception; dulled perception.
What does derealisation mean?
External world unfamiliar and the client may feel disconnected from surroundings. The surroundings can be seen as without colour or dreary. Things seem unfamiliar, dull or boring.
What does Depersonalisation mean?
Self perception is distorted and unfamiliar. The client feels unreal or dysmorphic. Severe depersonalisation can manifest in the client believing they are dead. Like an out of body experience
What does heightened perception mean?
Present as being extremely vivid. sounds and sights can be amplified or exaggereated with great attention to detail. Thing become more vivid.
What does Dulled Perception mean?
Present as being flat, dark and drab. Sounds and sights can feel ‘dirty’ or tastes are blunted. Excludes lack of interest in things. common in depression.
What does the thought process/content component of the MSE assess?
Refers to the way in which an individual puts together ideas and is observed through the clients pattern of speach
Assessment of this domain follows 3 main categories.
rate of production; continuity of ideas; disturbance in language (jumbled thoughts)
What is assessed in the rate of production in the process/content domain of the MSE?
Rate of production
- flight of ideas
- poverty of ideas (so jumbled, can’t orientate)
- slowed or hesitant thinking
- vague/perplexed.
What is assessed in the continuity of ideas in the process/content domain of the MSE?
- Tangetiality
- Circumstantiality (going around in clircles before answering)
- Loosening of associations (no direct links_
- Thought blocking (Difficulty getting the thought out)
- Poverty of thought
- Thought insertion/thought withdrawal (Thought insertion - can put thoughts into others; Thought withdrawal - others can read their thoughts)
- thought broadcasting
- Formal thought disorder
What is assessed in the disturbance in language in the process/content domain of the MSE?
- Perseveration
- Language disturbance - punning
- Neologisms (made up words)
- Clang associations
- Word salad (jumbled up in a big mes)
- Echolalia (repeats words or phrases)
What is assessed in the Perception component of the MSE?
Assessment centres on the following:
Delusions - are a false and firm belief held by the client despite objective evidence to challange the client and that is not accepted within cultural expectations.
What are the most common type of delusions?
There are many forms of delusions and the main delusions associated with Schizophrenia are
- Delusions of Persicusion
- Delusional mood
- Delusions of reference
- Delusions of control, influence or passivity
What are the levels of Consciousness?
Fully, Semi or unconscious. Overdose, substance intoxication or organic mental disorders can contribute
What are the 3 areas of the memory?
3 areas of memory assessment are immediate, recent and remote
What is assessed in Orientation?
Orientation is assessed by current time, place and person. Impairment can indicate organic brain disease. Impairments are usually detected in this order and resolve in reverse order.
