kneisl ch11 lecture STUDENT - Napa Valley College · 2015-01-22 · Carol Ren Kneisl • Eileen...

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Contemporary Psychiatric-MentalHealth Nursing

Third Edition

CHAPTER

Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff

Psychiatric-Mental Health Assessment

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Comprehensive Assessment

• Enables nurse to: –Make sound clinical judgments–Plan appropriate interventions


Psychiatric History*

• Current condition • Previous diagnosis • Previous interventions and treatments• Family history

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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.

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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*

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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

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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

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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

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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.

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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:

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Question #2

1.psychiatric history2.nursing plan of care3.physical assessment4.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.

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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.*

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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.

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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:

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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

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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

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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 Test2.State–Trait Anxiety Inventory 3.Minnesota Multiphasic Personality

Inventory-24.Sentence Completion Test


Psychological Testing: Cognitive Function*

• Wechsler Adult Intelligence Scale-IV• Raven’s Progressive Matrices Test • Benton Visual Retention Test

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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

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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.

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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]*

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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 diagnosis2.Axis II diagnosis3.Axis III diagnosis4.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

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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.

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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.

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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.

kneisl ch11 lecture STUDENT - Napa Valley College · 2015-01-22 · Carol Ren Kneisl • Eileen...

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