Contemporary Psychiatric-Mental Health Nursing Third Edition. Comprehensive Assessment. Psychiatric History* 10/9/2014.

Transcription

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 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* 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. Content of Thought* Special preoccupations and experiences Delusions, illusions, hallucinations Depersonalizations, obsessions, compulsions Phobias, fantasies, daydreams 5

6 Orientation* Time Place Person Self or purpose Memory* Attention span Ability to retain or recall past experiences Includes both recent and remote past General Intellectual Level* Nonstandardized evaluation of intelligence General grasp of information Ability to calculate Reasoning Judgment 6

7 Abstract Thinking* Ability to: Make distinctions between abstractions. Interpret simple fables or proverbs. Insight Evaluation* Recognizing the significance of the present situation Feeling the need for treatment Explaining the symptoms Making suggestions for treatment 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. 7

8 Question #1 A client presents to the mental health unit and asks to speak to the nurse. When the nurse first interacts with the client, the nurse will begin: Question #1 1.implementing nursing interventions. 2.planning to care for the client. 3.the assessment process. 4.evaluating the clients problems. Question #2 The nurse is collecting information about the clients, previous diagnosis, interventions, and treatment. This information will be documented in the: 8

9 Question #2 1.psychiatric history 2.nursing plan of care 3.physical assessment 4.physician s record Question #3 When assessing a client s psychiatric history, the nurse obtains information about the client s: Question #3 1.attitude. 2.appearance. 3.general behavior. 4.present symptoms. 9

10 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. 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.* 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

11 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. Question #4 When conducting a Mental Status Examination, the nurse gathers data related to the client s: Question #4 1.emotional state. 2.previous hospitalizations. 3.personality. 4.present symptoms. 11

12 Question #5 A client states I cannot die, I am invincible. The nurse documents the client s thought content as being consistent with: Question #5 1.flat affect. 2.nihilistic delusions. 3.delusions of self-deprecation. 4.flight of ideas. Question #6 The nurse is conducting a Mini-Mental State Examination on a client who reports just not being able to think clearly and an increasing awareness of can t seem to remember from one minute to the next. In order to ensure validity of the examination the nurse will: 12

13 Question #6 1.have the client also complete the Rorschach Test. 2.ask the client s significant other to verify the responses. 3.have the client write out the responses at the same time the nurse records the client s verbal responses. 4.ask the questions in the order they are listed on the tool. 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 Potential exposure to toxic substances Medications the client is taking 13

14 Observations* Gait Hygiene and dress Motor/neurological Weight Observe skin color 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. 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 14

15 Question #7 The nurse-therapist would refer an incarcerated client with a long history of antisocial behaviors to the psychologist for which of the following objective personality tests? Question #7 1.Raven s Progressive Matrices Test 2.State Trait Anxiety Inventory 3.Minnesota Multiphasic Personality Inventory-2 4.Sentence Completion Test Psychological Testing: Cognitive Function* Wechsler Adult Intelligence Scale-IV Raven s Progressive Matrices Test Benton Visual Retention Test 15

16 DSM-IV-TR 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-IV-TR 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 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 16

17 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. 17

18 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]* 18

19 Question #8 Using the DSM-IV-TR multiaxial system, the diagnosis of Bipolar Disorder Type II would be classified as an: Question #8 1.Axis I diagnosis 2.Axis II diagnosis 3.Axis III diagnosis 4.Axis IV diagnosis 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 19

20 Purposes of Assessment* Identify problems. Identify client motivations, strengths, resources. Identify internal and external forces that may hinder the therapeutic plan. 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. 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. 20

21 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. 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. 21

22 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. 22