Week 2: MSE, Risk Assessment Flashcards Preview

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Flashcards in Week 2: MSE, Risk Assessment Deck (51):

What are the 4 primary values that are needed integrated into practice?

1. Person centred and holistic healthcare.
2. Culturally safe health care.
3. Recovery oriented mental health care.
4. Trauma informed care.


What information does the MH assessment triangulate?

1. Clinical interview (which will elicit cross sectional and longitudinal histories (e.g. family Hx, mental health Hx, substance use Hx).

2. Behavioural observations (MSE)

3. Rating scales / assessment tools

[All whilst developing therapeutic alliance]


What are the goals of the initial assessment?

1. Establishing a therapeutic relationship.
2. Obtaining basic information about the person.
3. Developing a plan.
4. Decreasing the person's anxieties about therapy and treatment.
5. Building hope by communicating that the person is understood and can recover.


What things shape the context / process for assessment in MH nursing?

1. MH Act (each state has their own).
2. Policy and procedures locally (state/HHS/site).
3. Scope of practice and skills of the assessor.
4. Specialist clinicians to undertake assessment.
5. Preliminary vs ongoing assessment - the nurses role.
6. Goals of initial assessment will differ to an ongoing assessment.
7. Skill building and symptom management.


What traits and behaviours are expected of a MH nurse?

1. A critical observer
2. Conscientious attender - the nurse attends to both the process and content of the communication.
3. Critical self reflector - the nurse needs to monitor their feelings
4. Naive enquirer - blends specific questions into the flow of the interview and avoids asking "why"
5. Objective - defers judgment and analysis until the evidence is in


What forms the medical model approach to MH?

1. Diagnostic goal
2. Diagnostic & Statistical Manual (DSM V)
3. Bio psychosocial framework


What is the MH Assessment pathway?

1. Hx (developmental, social, medical, psychological, psychiatric)
2. Observation
3. MSE (theory, research, logical reasoning philosophy)

4. Formulation
5. Care plan
6. Care delivery

Strengths/opportunities, safety, suicide/harm risk


What are the primary assessment outcomes of a MHA

1. Assessment leads to clinical formulation.
2. Uses biopsychosocial approach
3. Why?
4. 5P's = presenting, predisposing, precipitating, perpetuating and protective factors.
5. Relevant to clinical presentation, the diagnosis the prognosis and the current risks.
6. Treatment plan, action plan, recovery plan, follow up MHA, admission, community, GP etc.
7. Risk mitigation - reduce / manage
8. Assessment is driven by professional respectful and clinically informed curiosity, underpinned by Roger's humane principles, and accepting of individual uniqueness


What tasks are undertaken in the initial phase of a MHA?

1. Build a therapeutic alliance
2. Obtain the psychiatric Hx
3. Interview for diagnosis
4. Negotiate a treatment plan with your Pt

Daniel Carlat (2005)
Instill hope throughout the interview.


Why is the clinical interview so important?

The assessment process in psychiatry relies primarily on the interviewing and observational skills of practitioners because there is no lab test, tissue diagnosis or imaging method available to confirm a psychiatric diagnosis.


What safety features need to be considered throughout MH nursing?

1. Providing for the safety of the consumer
2. Personal safety of the nurse
3. Environment
4. Strategies to feel safe
5. Exit points, team communication, team approach, consent, and permission, respect.
6. Noise, environment, comfort, nourishment, presentation


What are 4 key features of therapeutic engagement?

1. Reflect on the stages of relationship building (effective therapeutic alliance, Peplau, Rogers)
2. Recognise and validate that the the person is the expert of their own experience.
3. Hold hope (for the Pt)
4. Safety, collaboration, trust, empowerment.


What are the primary concerns of the opening phase?

- How do we ask questions?
- What brings them to you at this particular point in time?
- What assistance are they seeking?
- What do they see as the main problem?
- Consider how the Pt is presenting
- Decide interviewing priorities.


T/F = curious questions e.g. "why" should be utilised in the opening phase.



T/F = You should encourage the Pt to share their narrative experience.



T/F = open, closed and transitional questions can and should be utilised throughout the opening phase.



What does the MSE provide medical professionals?

It presents a snap shot of a persons mental state in a given period of time.
The MSE represents a cross section of the person's psychological life and the sum total of a clinician's observations and impressions at that moment.


What is the purpose of the MSE?

- Serves as a basis for future comparisons and tracking of progress.
- May illicit useful diagnostic information related to medical, neurobiological or psychiatric disorder that affects thought, emotion of behaviour
- Assessment should form the bases of planning and implementation
- Used across many disciplines, portable across practice orentations
- Provides cues for further testing that may be required.
- Frequently a component of referral documentation.


How do nurses obtain a MSE?

A MSE usually can take place in the course of some other activity (here during a comprehensive assessment), therefore there are only a few key areas that require focused attention.


What are the different aspects (overview) of a Mental State Exam?

- Appearance & behaviour
- Speech
- Mood & affect
- Thought form / process
- Thought content
- Perception
- Cognition
- Judgement/insight


In an MSE, the Pt's appearance is pertaining to their .....

It refers to the interviewee's overall appearance and physical impression.
Age / gender / cultural background / body size / clothes (appropriateness, clean. dishevelled, flamboyant) / grooming (odour, skin, hair, nails) / striking or unusual physical characteristics (tattoos, scars, needle marks, injuries.)


What are you specifically looking for regarding behaviour during an MSE?

- General body movements
- Gait
- Co-ordination
- Tics & tremors
- Mannerisms
- Purposeful vs disorganised
- Agitated
- Posture
- Eye contact (appropriate, intense, seductive, avoided)
- Facial expression (bizarre, inappropriate, startled, decreased variability of expression.
- Facial tics
- Rapport (easy or difficult)
- Reaction to examiner (uncommunicative/minimal information, friendly/ingratiating/seductive, suspicious/guarded/defensive, sarcastic/hostile/aggressive)


What are you specifically looking for regarding speech during an MSE?

- Use to assess variety of areas including social behaviours, thoughts, affect, obsessions etc.
- Rate / Volume / Quantity

- Mutism = no verbal response, yet individual indicates awareness of question
- Poverty of speech = restricted amount of spontaneous speech. Replies to questions are brief and monosyllabic.
- Pressured speech = speech is extremely rapid, difficult to interrupt, loud and hard to understand
- Aphasia = a loss of the ability to comprehend and/or express ideas through language


If an interviewee's mood is Euthymic, what does that typically mean?

Calm, comfortable, friendly, normal, pleasant, unremarkable


If an interviewee's mood is Euphoric, what does that typically mean?

Cheerful, ecstatic, elated, happy, jovial


If an interviewee's mood is Apathetic, what does that typically mean?

Bland, dull, flat


If an interviewee's mood is dysphoric, what does that typically mean?

despondent, distraught, grieving, hopeless, sad


If an interviewee's mood is apprehensive, what does that typically mean?

Anxious, fearful, frightened, high-strung, nervous, overwhelmed, panicked, tense, terrified, worried.


If an interviewee's mood is angry, what does that typically mean?

Irritable, sullen, outraged, irate, frustrated, furious.


During an MSE, what needs to be considered/known regarding Affect ?

Affect is described by labeling the apparent emotion conveyed by the person's nonverbal behaviour (anxious, sad etc), and also by using the parameters of appropriateness, intensity, range, reactivity, and mobility.
The external and observable verbal and nonverbal behaviour (facial expressions, body language, vocal tone).
Consider range of emotions displayed (full vs restricted).
Consider whether affect is congruent or incongruent with context (smiling whilst discussing loved one's funeral)


What are the 6 terms utilised to describe the interviewee's Affect during an MSE?

1. Full range (variations in expressions and gestures normally expected)
2. Restricted (limited variability of expressed emotion)
3. Blunted (reduction in expressed emotions or reduced intensity)
4. Flat (absence or near absence of expressed emotion)
5. Incongruent (outward expression of emotional state is not congruent with what they're expressing)
6. Labile (Expressed emotion fluctuates, variable beyond normal)


What is 'thought form' assessed according to?

- Amount of though and its rate of production
- Continuity of ideas: refers to the logical order of the flow of ideas
- Disturbances in language (use of words that do not exist or conversations that do not make sense).


Why is 'thought form' important?

It's important for the diagnosis of psychotic and mood disorders.


What are some examples of 'thought form' terminologies?

- Circumstantiality
- Flight of ideas
- Loose associations
- Tangentiality
- Word salad

Other peculiar thought forms:
- Clang associations
- Echolalia
- Neologism
- Perseveration
- Thought blocking


Throughout the MHA, the interviewee's thought content is a key parameter to diagnosis. What is the nature of an examinee's thoughts?

- Themes (suspicious, angry)
- Preoccupations
- Anti-social urges/attitudes
- Obsessions and compulsions
- Phobias or anxieties
- Harm to self or others
- Delusions


What are some examples of 'thought content'?

1. Delusions (of persecution / reference / control, influence or passivity - thought broadcasting / withdrawal / insertion)
2. Religious
3. Nihilist
4. Delusions of grandeur


What are the risks surrounding 'thought content'?

- Suicide areas to consider = Hx, hopelessness, thoughts, plans, means.
- Risk of violence areas to consider = Hx, substance abuse, antisocial attitudes / values, agitated/angry.
- Impulsivity = recent Hx; behaviour during interview.


How is perception utlised during an MSA?

Perceptual disturbances can be indicative of numerous disorders, including psychosis, schizophrenia, depression, substance misuse, neurological or organic disorders.
It is typically assessed by = observation (is the person responding auditory or visual stimuli that is not present), or direct questioning.


T/F = Hallucinations are a true sensory experience

hallucinations are a false sensory experience in which the individual sees, hears, smells, senses or tastes something that others cannot.


What are the different types of perception?

1. Auditory (hearing)
2. Visual (seeing)
3. Olfactory (smelling)
4. Gustatory (tasting)
5. Tactile (feeling)


What is derealisation?

It is part of perception, and dissociative symptoms. It is where the external world seems strange or unreal.


What is depersonalisation?

It is part of perception, and dissociative symptoms. The person feels detached from their own thought processes or body.


What are illusions?

It is a part of perception. A person misinterprets sensory stimuli (e.g. hearing rustling leaves as voices)


How does cognition tie into the MHA? And what do you need to consider

Cognition is the ability to know and think, using intellect, logic, reasoning, memory and all of the higher cortical functioning. Its purpose is to determine if a person is alert, and orientated to time and place.

- Orientation
- Memory
- Attention
- Concentration
- Abstract thinking.


What is the cognition MMSE?

The mini mental state exam (MMSE) is a brief measure of cognitive status in adults.
It is utilised to screen for cognitive impairment, to estimate the severity of cognitive impairment at a given point in time, to follow the course of cognitive changes in an individual over time.

It's typically not part of the MSE unless there are obvious cognitive deficit concerns.


What do you need to consider and estimate regarding cognition - intelligence?

It provides an estimation in identifying an individuals personal strengths, helpful modes of treatment and premorbid functioning.

Consider =
- Education level
- Socioeconomic status
- Occupation
- Vocabulary


Why is judgment important to analyse during an MSE?

It refers to the ability to assess a situation correctly and act appropriately within that situation = described as good/poor/impaired.


What is insight and how may it be beneficial?

Refers to examinee's degree of awareness and understanding of their problem/illness.
It may assist in predicting or understanding compliance with treatment.
"Lack of Insight" may actually be denial, or a coping strategy.


What are the 4 levels of insight?

1. No insight
2. Poor
3. Fair
4. Good

If seeking to increase insight, MUST balance this with increasing hope.


What is anosognosia?

an inability or refusal to recognize a defect or disorder that is clinically evident.


What is typically included in a risk assessment?

- Suicide
- Violence & aggression
- Vulnerability
- Absent without approval (absconding)

Risk also assesses impulsivity, reliability of assessment, strengths and protective factors and resilience of the person