Objective 2 Flashcards by Kaitlyn Dominie

what are the categories of psychiatric history?

current condition
previous diagnosis
previous interventions and treatments
family history

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what are the categories of data?

complaint/reason for admin
present symptoms
previous hospitalizations and treatments
personal history
personality

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what is the significance of psychiatric mental health nursing assessment?

Establish rapport
* Obtain understanding of current problem
* Review physical status and obtain baseline VS
* Assess risk factors associated with safety of patient or
others
* Perform a mental status assessment
* Assess psychosocial status
* Identify mutual goals for treatment
* Formulate a plan of care

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Useful tools include storytelling, dolls, drawing, and
games to promote disclosure

assessment of children

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Particularly concerned about confidentiality
 Threats of suicide or homicide, use of illegal drugs, or
issues of abuse cannot be kept confidential and must
be shared with other professionals and parents

assessment of adolescents

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Be aware of physical limitations such as a sensory,
motor, or medical condition that could cause
increased anxiety, stress, or physical discomfort for
the patient
 Make accommodations at the beginning of the
interview when possible (hearing, sight)
 High pitch voice may increase anxiety
 Sit close but not to invade the pt’s personal space

assessment of older adults

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steps of cultural competence during assessment

Assess and clarify the client’s cultural values, beliefs,
and norms
Assess the client’s degree of cultural
assimilation/acculturation
Assess the client’s perspective regarding feelings and
symptoms
Elicit the client’s expectations and ask what is
important for the health care provider to know
Learn how to work with interpreters
When using an interpreter, talk to the client rather
than the
interpreter (observe eyes/face for nonverbal)
Seek collaboration with bilingual community
resources (social
worker in meeting)

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Review of systems
 Laboratory data
 Mental status examination [MSE] (Box 6-3)
 Psychosocial assessment (Box 6-4)
 Spiritual/religious assessment
 Cultural and social assessment
Standardized nursing assessment tools facilitate the
assessment process (Table 6-2)

gathering data

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(old medical records, family)

validate data

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what do we assess during mental status assessment?

intelligence
thought processes
capacity for insight

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Data related to client’s
 Biological
 Psychological
 Cultural
 Spiritual
 Social needs
* Completed in collaboration with other health
care professionals

comprehensive assessment

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Collection of data regarding a particular
problem as determined by:
 Client
 Family member
 Crisis situation

focused assessment

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Collection of predetermined data usually during initial
contact, to determine how client is functioning in various
areas
* Includes use of assessment or rating scales to evaluate
data regarding a specific problem (memory loss or
insomnia) or behavior (combativeness or impulsivity)

screening assessment

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A type of screening assessment that can be used in
variety of settings to describe appearance, speech, mood,
thinking, perceptions, sensorium, insight and judgment

psychiatric mental status exam

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Screens for cognitive impairment and dementia
 Used to estimate level of cognitive impairment
at a given point in time
 The maximum score is 30. A score of 23 or lower
is indicative of cognitive impairment
 Takes only 5-10 minutes to administer and is
therefore practical to use repeatedly and
routinely

Folstein’s mini mental state exam

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what is the purpose of the mental status exam?

Gather objective data.
* Deal immediately with any
risk of violence or harm.
* The MSE can change from
day to day or hour to hour
* It is the description of the
patient’s appearance,
speech, actions, and
thoughts throughout the
interview.

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Psychological equivalent of a physical exam that
describes the mental state and behaviors of the
person being seen including objective
observations and subjective descriptions
provided by the client
* Provides information for the diagnosis and
assessment of disorder and response to
treatment
* A mental status exam provides a snap shot at a
point in time

mental status exam

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what are the steps in collection of data

appearance
affect or emotional state
behaviour, attitude, and coping patterns
communication and social skills
content of thought
orientation
memory
intellectual ability
insight regarding illness
spirituality
sexuality
neurovegetative changes

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A form of nonverbal communication where
thoughts feelings and moods and conveyed

appearance

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what do we observe during appearance?

Apparent age (relationship between appearance &
age)
* Peculiarity of dress
* Cleanliness (hygiene & grooming)
* Use of cosmetics
* Pupil dilation, facial expression
* Height, weight, nutritional status
* Present of scars, tattoos, body piercings

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Body movements
Level of eye contact (be mindful of cultural
differences)

behaviour (observed)

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Rate & tone
Volume
Disturbances
Cluttering

speech (observed)

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what do we observe when assessing behavior attitude and oping patterns?

suicide
violence
substance abuse

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Emotional experience over prolonged period of
time
 Tone (sad, euphoric, depressed)
 Degree (mild, moderate, extreme)
 Irritability (calm, irritable, explosive)
 Stability (rapid or delayed)

mood (inquired)

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Immediate expressions of emotions  Range  Appropriateness & Stability

affect (observed)

An individual’s present emotional responsiveness  Temporary expression of feelings or state of mind  Nonverbal  Facial expressions, gestures  Differs from mood  Are the two congruent?  Affect can be incongruent from what one says or does

affect or emotional state

Severe reduction or limitation in intensity of one’s affective response to a situation

blunted

Absence or near absence of signs of affective responses (immobile face, monotonous tone of voice)

flat

Discordance (lack of harmony) between one’s voice and movements with one’s speech or verbalized thoughts

inappropriate

Abnormal fluctuation or variability of one’s expressions (repeated, rapid or abrupt shifts)

labile

Reduction in one’s expressive range and intensity of affective responses

restricted or constricted

what are the factors to consider when assessing attitude?

Is behaviour strange, threatening, suicidal, self injurious or violent? * Is client trying to control emotions? * Any unusual mannerisms or motor activity such as grimacing, tremors, tics, impaired gait, psychomotor retardation or agitation? Excessive pacing? * Are they friendly, embarrassed, fearful, resentful, angry, negativistic or impulsive? * Attitude toward interviewer or others can facilitate or impair the assessment process * Is behaviour overactive or hyperactive? Is it purposeful, disorganized, stereotyped? * Are actions consistent?

what are the communication and social skills for impaired communication?

blocking circumstantiality clang association echolalia flight of ideas looseness of association mutism neologism perseveration tangentiality verbigeration word salad

Disorganized, coherent, flight of ideas, neologisms, thought blocking, circumstantiality

thought process

Delusions, jealousy, thought control/withdrawal/insertions, obsessions or preoccupations

thought content

Fixed or false beliefs not true to fact & not ordinarily accepted by other  Occur in clients with various psychotic disorders

delusions

what are the types of delusions frequently reported?

Delusion of reference or persecution * Delusion of alien control * Nihilistic delusion * Delusion of poverty * Delusion of grandeur * Somatic delusion

Feeling of unreality or strangeness concerning self, environment or both * Clients describe out of body experiences * Common in schizophrenia, bipolar disorders, depersonalization disorders

depersonalization

what are the obsessions of content of thought?

Insistent thoughts, recognized as arising from self * Seen in those with anxiety or obsessive compulsive disorder

what are the compulsions associated with content of thought?

Insistent, repetitive, intrusive and unwanted urges to perform an act contrary to one’s ordinary wishes or standards * Repetitive urge to gamble although partner threatens divorce if don’t stop playing poker * If don’t engage in act, feel tension and anxiety * Seen in those with anxiety, obsessive compulsive disorder or personality body dysmorphic, eating or autism spectrum disorders

Sensory perceptions in the absence of an actual external stimulus

hallucinations

what are the types of hallucinations?

auditory visual olfactory gustatory tactile

Hears voices frequently telling client when to eat, dress and go to bed each night

auditory

Describes seeing spiders and snakes on ceiling of room

visual

States “smells rotten garbage” but not evidence of any foul smelling material

olfactory

Complains of constant taste of salt water in mouth

gustatory

Client going to alcohol withdrawal and delirium tremens

tactile

Misperception of a real external stimulus such as, noise or shadows * Ex: dementia patients interpret rustling of leaves as voices * Also common in symptoms of withdrawal from alcohol/other substances

illusions

what are the common dissociations for illusions?

Feeling detached, surroundings not real

what are the things to looks for when assessing cognition (inquired)?

Orientation (person, place, time)  Level or consciousness (alert, confused, stuporous)  Memory functioning (remote, recent, immediate)  General Knowledge (compared to average person)  Language (following instructions)  Attention (performance on tests with #’s)  Abstraction (performance on tests with similarities)  Visual or special processing  Insight (self-understanding)  Judgement (problem-solving)

what are the things to look for when you assess orientation?

1.Person 2.Place 3.Time 4.Level of orientation and consciousness  Confusion  Clouding of consciousness  Stupor  Delirium  Coma

Disorientation to person, place or time, characterized by bewilderment and complexity

confusion

Disturbance in perception or thought that is slight to moderate, usually due to physical or chemical factors producing functional impairment of the cerebrum

clouding of consciousness

A state in which the client does not react to or is unaware of his or her surroundings. May be motionless and mute but conscious

stupor

Confusion accompanied by altered or fluctuating consciousness. Moderate to severe disturbance in emotion, thought and perception, usually associated with infections, toxic states, head trauma, etc

delirium

Ability to recall events in the immediate past and for up to 2 weeks previously

recent memory

Ability to recall remote past experiences such as the date and place of birth, names of schools attended, occupational history, chronologic data related to previous illnesses

long-term memory

what are some memory disorders?

hypermnesia amnesia paramnesia

abnormally pronounced memory

hyperamnesia

loss of memory

amnesia

falsification of memory

paramnesia

Ability to use facts comprehensively

intellectual ability

what must u ask a pt when assessing intellectual ability?

 Names of persons or places (last three Prime Ministers)  Mathematical questions (calculate simple math problems)  Ability to form opinions (what would you do if you found a wallet in front of your house?)

Make distinctions between abstractions  Interpret simple fables or proverbs

abstract thinking

Self understanding or the extent of one’s understanding about the:  Origin  Nature  Mechanism of one’s attitudes or behaviour

insight

Should determine  Denomination  Beliefs  Spiritual practices  Spiritual support system  Are beliefs used as a coping mechanism?

spirituality

Use non-gender-specific terms during interview (eg: partner, them/they) * Sexual identity * Gender identity * Sexual orientation * Assess client’s comfort level when discussing sexuality

sexuality

what are neurovegetative changes?

sleep patterns' eating patterns' energy levels sexual functioning elimination patters

Asking clients about their sleep patterns and any problems with sleeping is an often- neglected, but extremely important, area to investigate: * Insomnia * Acute or primary insomnia * Secondary insomnia

sleep patterns

Difficulty initiating and maintaining sleep

insomnia

Sleepiness and alertness that occur at an inappropriate time of day relative to local time, occurring after repeated travel across more than one time zone

jet lag

Overwhelming sleepiness in which irresistible attacks of refreshing sleep, cataplexy (loss of muscle tone) and/or hallucination or sleep paralysis at beginning or end of sleep episodes

narcolepsy

Repeated awakenings from major sleep or naps with detailed recall of extended or extremely frightening dreams, usually involving threats to survival, security or self esteem

nightmare disorder

Characterized by insomnia associated with crawling sensations in lower extremities, frequently associated with medical conditions such as arthritis or pregnancy

restless leg syndrome

Breathing related sleep disorder due to disrupted ventilation or airway obstruction with lack of airflow. Normal sleeping pattern completely disrupted several times throughout night

sleep apnea

Recurrent episodes of abrupt awakening from sleep usually accompanied by panicky scream, intense fear, tachycardia, rapid breathing and diaphoresis * unresponsive to efforts of others to provide comfort and no detailed dream recall

sleep terror disorder

how do we assess for ideas of harming self or others?

Inquire about suicidal or homicidal thoughts  Target (self or other)  Frequency  Intent  Plan (Lethality of means, means or opportunity to carry out the plan

how do we assess pain?

Assess level of pain using pain intensity age- appropriate rating scale  Client self report of pain most reliable indicator  If unable to verbally communicate look at nonverbal

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.

global assessment of functioning

a handbook for mental health professionals that lists different categories of mental disorders and the criteria for diagnosing them The manual has been revised six times since its inception Organizes each psychiatric diagnosis according to different aspects of a specific disorder or disability

DSM-V

informal supporters or caregivers are prone to:

depression anxiety grief fatigue changes in social relationships other issues

what do we document for assessment data?

Objective * Descriptive * Complete * Legible * Dated * Logical * Signed