Contemporary Psychiatric-Mental Health Nursing Third Edition. Comprehensive Assessment. Psychiatric History 8/16/2016.

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Marion Sparks
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Make sound clinical judgments Plan appropriate interventions Psychiatric History

1 Contemporary Psychiatric-Mental Health Nursing Third Edition CHAPTER 11 Psychiatric- Mental Health Assessment Comprehensive Assessment Enables nurse to: Make sound clinical judgments Plan appropriate interventions Psychiatric History Current condition Previous diagnosis Previous interventions and treatments Family history 1

2 Categories of Data Complaint/reason for admission Present symptoms Previous hospitalizations and treatments Personal history Personality Collecting the Data The interview: Gather information. Establish rapport. Structure the interview. Keep the pace comfortable. Interviewing Basics Do not rush the client in gathering the data. Respect the client s need for minimal distractions. 2

3 Mental Status Examination (MSE) Purpose: Gather objective data. Deal immediately with any risk of violence or harm. MSE Categories General behavior, appearance, attitude Characteristics of speech Emotional state Content of thought: CIA bugging the walls? Orientation MSE Categories (cont'd) Memory General intellectual level Abstract thinking Insight evaluation Summary 3

4 General Behavior, Appearance, Attitude Physical characteristics Apparent age Manner of dress Use of cosmetics Personal hygiene Responses to the examiner General Behavior, Appearance, Attitude (cont'd) Also included: Posture Gait Gestures Facial expression Mannerisms Client s general activity level Characteristics of Speech Loudness Flow Speed Quantity Level of coherence Logic 4

5 Emotional State Evaluate pervasive or dominant mood or affective reaction. Identify objective and subjective data. Emotional State (cont'd) Pay attention to: Constancy. Change. Use descriptive terms. See page 207 Composed, frank, tense, aloof, disdainful, sarcastic, apathetic, affectless Content of Thought Special preoccupations and experiences Delusions, illusions, hallucinations Depersonalizations, obsessions, compulsions Phobias, fantasies, daydreams See next slide for definitions 5

6 Vocabulary Delusion: persistent, aberrant belief or perception held inviolable by a person despite evidence to the contrary. I cannot die, I m invincible! Nihilistic delusion Illusion: false interpretation of an external stimulus, usually visual or auditory, ex.: mirage in the desert or voices on the wind. Hallucination: a sensory perception that does not result from an external stimulus and occurs during a waking state. Vocabulary cont. Depersonalization-derealization disorder occurs when you persistently or repeatedly have the feeling that you're observing yourself from outside your body or you have a sense that things around you aren't real, or both. Obsessions: a persistent thought or idea with which the mind is continually and involuntarily preoccupied and suggests an irrational thought Compulsions: an irresistible, repetitive, irrational impulse to perform an act that is usually contrary to one s ordinary judgements or standards yet results in over anxiety if it is not completed. Mosby s Medical, Nursing & Allied Health Dictionary 4 th edition Phobias: anxiety disorder characterized by an obsessive, irrational and intense fear of a specific object ex. Animal, dirt, snakes, clowns Agoraphobia: fear of crowded spaces or public areas Nyctophobia: fear of the dark Fantasies: the mental process of transforming undesirable experiences into imagined events or a sequence of ideas in order to fill an unconscious wish, need or desire or to give expression to unconscious conflicts, such as a daydream 6

7 Orientation Time Place Person Self or purpose Memory Attention span Ability to retain or recall past experiences Includes both recent and remote past Events leading to present seeking for treatment NSH : Do you know why you re here? Retention and recall Motorcar, teacup lillies After 5 min. can they recall these? General Intellectual Level Non-standardized evaluation of intelligence General grasp of information Who is president of the US? Governor of CA? Ability to calculate: simple multiplication, serial 7s count back from 100 Reasoning & Judgement What would you do with a gift of $10,000 be aware of your own biases 7

8 Abstract Thinking Ability to: Make distinctions between abstractions. Interpret simple fables or proverbs. What s the difference between poverty and misery? What does Don t cry over spilled milk mean? Insight Evaluation Recognizing the significance of the present situation Feeling the need for treatment Explaining the symptoms Making suggestions for treatment NSH: Do you think you have a mental illness? Summary Conclude the examination with important psychopathologic findings and a tentative diagnosis. Pertinent facts from the medical history and/or physical examination should be added. 8

Mental Status Examination Data to determine etiology, diagnosis, prognosis, safety issues More comprehensive than Mini-Mental State Exam Identify the personal present mental status.

9 Mental Status Examination Data to determine etiology, diagnosis, prognosis, safety issues More comprehensive than Mini-Mental State Exam Identify the personal present mental status. Sequence in obtaining the data can vary. Break time Mini-Mental State Exam Questions must be asked in the order they are listed. Cover the scope of a client s thinking and reactions. Total score indicates the likelihood and level of cognitive decline. The maximum score is 30 points. 9

Mini-Mental State Exam (cont'd) It is used if there is not enough time to complete a full MSE. Main focus of the exam is cognitive functioning, but mood can be assessed.

10 Mini-Mental State Exam (cont'd) It is used if there is not enough time to complete a full MSE. Main focus of the exam is cognitive functioning, but mood can be assessed. Mini-Mental State Exam (cont'd) Client must be able to see and write. If client is unable to perform an activity, use Mental Status Examination. Handout Mini mental status exam 10

11 Biologic and Neurologic Assessment Objectives Detection of underlying/unsuspected organic disease Understanding of disease as a factor in the overall psychiatric disability Appreciation of somatic symptoms that reflect psychological rather than physiologic problems Biologic History Facts about known physical diseases and dysfunction Information about specific physical complaints General health history Occupational assessment Air traffic controller, veteran of war Potential exposure to toxic substances Lead, poisons Medications the client is taking Legal/illicit/OTC Observations Gait Hygiene and dress Motor/neurological Weight Observe skin color Why? Jaundice Cyanotic 11

12 Neurologic Assessment It is mandatory for each client suspected of having brain dysfunction. Goal is to discover signs pointing to cerebral dysfunction or cerebral disease. Positron-emission Tomography Detect seizure activity. Evaluate sleep disorders. Detect disorders, trauma, and strokes. Examine the blood flowing to the brain. Identify cerebral atrophy, cerebral hemorrhage, cerebral infarct, hematomas, and abscesses. Psychological Testing: Personality Objective personality tests Minnesota Multiphasic Personality Inventory-2, State-Trait Anxiety Inventory, Millon Clinical Multiaxial Inventory-II, and Beck Depression Inventory Projective personality tests Rorschach Test, Thematic Apperception Test, Sentence Completion Test 12

13 MMPI Minnesota Multiphasic Personality Inventory -2 True/false questions Personality test Sample questions Psychological Testing: Cognitive Function Wechsler Adult Intelligence Scale-IV Raven s Progressive Matrices Test Benton Visual Retention Test 13

14 DSM-V Multiaxial System It is evaluated on five axes, each dealing with a different class of information about the client. Multiaxial assessment is congruent with holistic views of people. It recognizes the role of environmental stress in influencing behavior. Data addresses adaptive strengths as well as symptoms or problems. DSM-V Multiaxial System Axis I: Clinical disorders Axis II: Personality disorders/intellectual disabilities Axis III: Present medical conditions Axis IV: Psychosocial/environmental factors affecting client Axis V: Global Assessment of Functioning (GAF) See appendix A pp Axis I: Clinical Disorders Includes all Adult and Child Clinical Disorders Includes psychological factors that would affect a physical condition: Medication-induced movement disorders, relational problems, and others page

15 Axis I: Clinical Disorders (cont'd) Includes conditions which may be a focus but may not constitute a clinical syndrome: Marital problems Occupational problems Parent-child problems Axis II: Personality Disorders Contains: Personality disorders diagnosed in adults Intellectual disabilities diagnosed in children and adolescents It is also used to report maladaptive personality traits. Axis III: General Medical Conditions Physical disorders and medical conditions that must be taken into account in planning treatment They are relevant to understanding the etiology or worsening of the mental disorder. 15

16 Axis IV: Psychosocial/Environmental Factors Affecting Client Problems with primary support group Problems related to the social environment Educational problems Occupational problems Axis IV: Psychosocial/Environmental Factors Affecting Client (cont'd) Housing problems Economic problems Problems with access to health care services Problems related to interaction with the legal system/crime Axis V: Global Assessment of Functioning Information is used to plan treatment. Develop nursing diagnosis. Predict outcomes Set goals for client behavior. Measure impact of treatment Evaluate client response to goal/treatment. [Refer to Appendix A: Global Assessment of Functioning] 16

Psychosocial Assessment Dynamic process begun during initial contact Includes identifying characteristics such as name, gender, age, marital status, ethnic and cultural origins Individual, family, or

17 Psychosocial Assessment Dynamic process begun during initial contact Includes identifying characteristics such as name, gender, age, marital status, ethnic and cultural origins Individual, family, or group assessments Break time Purposes of Assessment Identify problems. Identify client motivations, strengths, resources. Identify internal and external forces that may hinder the therapeutic plan. 17

18 Purposes of Assessment (cont'd) Set reasonable goals with the client. Determine appropriate intervention strategies. Provide continuous evaluation and indicate when therapeutic plan should be changed. Documentation Systems Nursing care plans Individualized care plan Critical pathways Scheduled path; labs, treatments, tests Algorithms step by step mathematical / logical Quality Assurance An ongoing effort to find new and better ways of conducting care and achieving better results Best conducted by the people doing the work rather than by supervisors and administrators 4 basic steps: Plan, Do, Check, Act 18

19 Resources APNA The American Psychiatric Nurses Association is the specialty organization for nurses engaged in various levels of psychiatric nursing. This site includes standards and competencies for practice. Resources (cont'd) Priory Medical Journals This Priory Medical Journals site provides a glossary of terminology used in psychiatry. Resources (cont'd) WebMD Mental Health Assessment This WebMD site explains the process and purposes of mental health assessment in easy-to-understand terms. 19

20 Resources (cont'd) Citizen s Guide to Preventing and Reporting Elder Abuse Addresses areas of elder abuse, explains who to report elder abuse to, and provides websites for additional information. Resources (cont'd) Mental Health America The site provides information about local services, support groups, and access to mental health care. Resources (cont'd) DANA Foundation The Dana Foundation is a private philanthropy which serves as a gateway to general information about the brain and current brain research. 20

Contemporary Psychiatric-Mental Health Nursing. Comprehensive Assessment. Scope of Practice. Chapter 11 Assessment

Contemporary Psychiatric-Mental Health Nursing Chapter 11 Assessment Comprehensive Assessment Enables nurse to: Make sound clinical judgments Plan appropriate interventions Scope of Practice Collect and