ST. JOSEPH’S COLLEGE
Institute of Nursing
Psychiatric Nursing NCM 204
Prof. Andy Lynn Noble- Hizo, RN, MAN
ASSESSMENT OF PSYCHIATRIC-MENTAL HEALTH CLIENTS
The nursing process is a six step problem-solving approach to nursing that also serves as an organizational framework for the practice of nursing. It sets the practice of nursing in motion and serves as a monitor of quality nursing care. Nurses in all specialties practice the first step, assessment of clients with psychiatric disorders.
STANDARD I ASSESSMENT- collection of health data.
STANDARD II DIAGNOSIS – analysis of data to determine diagnosis
STANDARD III IDENTIFICATION – identification of expected outcomes
STANDARD IV PLANNING – development of a plan of care to attain expected outcomes
STANDARD V IMPLEMENTATION- implementation of interventions identified in the plan of care
STANDARD VI EVALUATION – evaluation of progress in attaining expected outcomes
CLIENT ASSESSMENT__________________________________________________
TWO TYPES OF DATA:
OBJECTIVE – data include information obtained verbally from the client, as well as the results of inspection, palpation, percussion and auscultation.
SUBJECTIVE – data include information obtained from the client, family members or significant others during direct questioning and during health history taking.
The Essay on Developing nursing standards of practice 2
These are the process for the developing nursing standards of practice Standard 1: Assessment: The registered nurse collects comprehensive data about patient’s health. Standard 2: Diagnoses: The registered nurses analyze the assessment data to determine the diagnoses or the issues. Standard 3: Outcome identification: The registered nurse identifies the expected outcomes for the patient’s plan of ...
TYPES OF ASSESSMENT:
COMPREHENSIVE ASSESSMENT – includes data related to the client’s biologic, psychological, cultural, spiritual and social needs.
– Generally completed in collaboration with other health care professionals such as physician, psychologist, neurologist and social worker.
– Physical exam is performed to rule out any physiologic causes of disorders such as anxiety, depression or dementia.
– Many psychiatric facilities require comprehensive assessment, including medical clearance, before or within 24 hours of admission to avoid medical emergencies in a psychiatric setting.
FOCUSED ASSESSMENT – includes the collection of specific data regarding a particular problem as determined by the client, a family member or a crisis situation. (Ex: suicide attempt)
SCREENING ASSESSMENT – includes the use of specific screening instrument to evaluate data regarding a particular problem, such as a movement disorder exhibited by a client taking neuroleptic medication to stabilize clinical symptoms of schizophrenia.
– Uses nursing history and assessment too to obtain factual information observe client appearance and behavior and evaluate client’s cognitive and mental status.
CULTURAL COMPETENCE DURING ASSESSMENT
Cultural competence experts realize that nurses cannot learn the customs, languages and specific beliefs of every client they see. But the psychiatric nurse must possess sensitivity, knowledge and skills to provide care to culturally diverse groups of clients to avoid labeling persons as noncompliant, resistant to care or abnormal. For example, the act of suicide is accepted in some cultures as a means to escape identifiable stressors like marital discord, illness, criticism from others and loneliness.
5 GENERAL APPROACHES IN ASSESSING AND TREATING DIVERSE CLIENTS:
1. Try to understand the client’s perspective feelings and symptoms. Questions include “What do you call your illness?”, “What do you think causes it?” or “Have you treated it?”
The Term Paper on The Role of and Emergency Room Nurse
The role of an emergency room nurse can be demanding and may require a nurse to use many different nursing skills at certain times to take care of a variety of patients. The main role is the nurse must be skilled in client assessment, priority setting, critical thinking, multitasking, and communication. The nurse must be knowledgeable and able to make some decisions independently. The nurse also ...
2. Learn how to work with interpreters. The use of a family member as an interpreter is contraindicated because a family member may omit data or give erroneous information.
3. When using an interpreter, talk to the client rather than the interpreter. Observe the client’s eyes and face for nonverbal reactions.
4. Negotiate treatment. Explain what assessment tools may be used. Ask the client if there is a need o clarify any information as the assessment process occurs.
5. Seek collaboration with bilingual community resources, such as a social worker, for assistance in meeting biopsychological needs of clients who have difficulty communicating in a second language.
Talking openly and communicating with the client can provide valuable information about compliance and behavior. The most important thing the psychiatric nurse can do is to acknowledge that differences do exist.
ASSESSMENT
DATA COLLECTION __________________________________________
The following are the data to be collected by the nurse during a comprehensive assessment conducted in the psychiatric setting.
1. APPEARANCE
– This includes physical characteristics, age, and peculiarity of dress and use of cosmetics.
– Facial expressions should also be observed as this indicates emotions, feelings and moods.
– Manic clients may dress in bizarre or overly colorful outfits, wear heavy layers of cosmetics and don several pieces of jewelry.
2. AFFECT OR EMOTIONAL STATE
AFFECT- is the outward manifestation of a person’s feelings, tone, and mood.
– The terms affect and emotions are commonly used interchangeably.
– A lead question such as “What are you feeling?” elicits responses like nervousness, anger, depression or confusion and should be asked to describe the said feelings.
– Is the person’s emotional response constant or does it fluctuates during assessment?
– Nurse should record a verbatim reply to questions concerning mood and note whether an intense emotional response accompanies the discussion of a specific topic.
– Responses may be appropriate, inappropriate, flat or blunted.
The Essay on The Assessment Process
There are three phases in the helping process, these phases include the following: Assessment The assessment phase is one of the most important phases, in this phase the client and professional make their first initial contact with one another and during this phase the professional will evaluate the client to see if they are a good candidate for services and if they meet the eligibility ...
– Examiner or observer must identify the abnormal reaction and explore its depth, intensity and persistence.
Appropriate affect – harmony between the stimuli and emotional reaction.
Inappropriate affect – disharmony between the stimuli and emotional reaction.
Flat affect – absence of emotional reaction.
Blunt affect – reduction or delayed in emotional reaction.
3. BEHAVIOR, ATTITUDE AND COPING PATTERNS
The nurse assesses client’s behavior and attitude by considering the following factors:
• Do they exhibit strange, threatening, suicidal, self-injurious or violent behavior? Are they making an effort to control their emotions?
• Is there evidence of any unusual mannerisms or motor activity such as grimacing, tremors, tics, impaired gait, psychomotor retardation or agitation? Do they pace excessively?
• Do they appear friendly, embarrassed, evasive, fearful, resentful, angry, negativistic or impulsive? Their attitude toward the interviewer or other helping persons can facilitate or impair the assessment process.
• Is the behavior overactive or underactive? Is it purposeful, disorganized or stereotypes? Are reactions fairly consistent?
If they are in contact with reality and able to respond to such questions, clients should be asked how they normally cope with a serious problem or with high levels of stress.
Responses to these questions enable the nurse to assess client’s present ability to cope and their judgment.
Paranoid or suspicious clients may isolate themselves, appear evasive during a conversation and demonstrate a negativistic attitude toward the nursing staff. Such an activity is an attempt to protect oneself by maintaining control of a stressful environment.
4. COMMUNICATION AND SOCIAL SKILLS
“The manner in which the client talks enable us to appreciate difficulties with his thought processes. It is desirable to obtain a verbatim sample of the stream of speech to illustrate psychopathologic disturbances.” (Small, 1980)
FACTORS TO CONSIDER IN CLIENT’S ABILITY TO COMMUNICATE:
– Do they speak coherently? Does the flow of speech seem natural and logical or is it illogical, vague and loosely organized? Do they enunciate clearly?
The Essay on Critical Thinking One Thought Word
Critical thinking is a way, style, path, or movement of thought in which an individual uses to find deeper meanings to everyday events or situations. Critical thinking straddles and revolves around philosophy and when asked to define critical thinking is, then philosophy plays a role. To attempt to define critical thinking, the phrase must be divided into separate words. The word "critical" can ...
– Is the rate of speech slow, retarded or rapid? Do they fail to speak at all? Do they respond only when questioned?
– Is there a delay in answers or responses, or do clients break off their conversation in the middle of a sentence and refuse to talk further?
– Do clients whisper or speak softly or do they speak loudly or shout?
– Do they repeat certain words and phrases over and over?
– Do they make up new words that have no meaning to others?
– Is their language obscene?
– Does their conversation jump from one topic to another?
– Do they stutter, lisp or regress in their speech?
– Do they exhibit any unusual personality traits or characteristics? Are they loners or aggressive or domineering during interview?
– Do they feel that people like them or reject them?
– How do they spend their personal time?
– With what cultural group or group do they belong?
Impaired Communication
The following terminologies are commonly used to describe impaired communication observed during assessment process:
Blocking- is a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Blocking may be due to preoccupation, delusional thoughts or hallucinations. It is most often found in schizophrenic clients during auditory hallucinations.
Circumstantiality- client gives much unnecessary detail that delays meeting a goal or stating a point. This impairment is commonly found in clients with manic disorder and clients with some cognitive impairment disorders such as early stage of dementia or mild delirium. Substance abusers may exhibit this pattern of speech.
Tangentiality – client gives too much unnecessary details without going to meet the goal or point.
Word salad – incoherent mixture of words and phrases.
Echolalia – repetition of words of others.
Clang association – the sound of the word gives direction to the flow of thought.
Flight of Ideas- characterized by over productivity of talk and verbal skipping from one idea to another. The ideas are fragmentary although talk is continuous. Example: “I like the color blue. Do you ever feel blue? Feelings can change from day to day. The days are getting longer.” It is most common in clients with manic disorders.
The Essay on Multiple Personality Disorder 2
More than two million cases can be found altogether in psychological and psychiatric records of multiple personality disorder, which is also known as dissociative identity disorder. Sometimes people have thought that multiple personality disorder is a trick, committed by manipulative, attention-seeking individuals. But through a series of studies is has been proven otherwise. Multiple personality ...
Looseness in association- shifting of a topic from one subject to another is a completely unrelated way.
Perseveration- persistent, repetitive expression of a single idea in response to various questions. This is found in clients experiencing some cognitive impairment and catatonia.
Verbigeration- is meaningless repetition of incoherent words or sentences. It is seen in clients with certain psychotic reactions or cognitive impairment.
Neologism – coining or a new word or several words or self-invented by person that are not understood by others. “His phenologs are in the dryer.” It is found in schizophrenia.
Mutism- refusal to speak even though the person may give indications of being aware of the environment. It ay occurs consciously or unconsciously and is observed in catatonic schizophrenia, depressive disorders, organic or psychogenic stupor.
5. CONTENT OF THOUGHT
The following is a brief summary of alterations in thought processes frequently seen in the psychiatric clinical setting. Alterations in thought process can be related to a functional emotional disorder (depression) or to an organic condition (dementia).
Delusions
• Delusions are fixed false beliefs not true and not ordinarily accepted by other members of the person’s culture.
• They cannot be corrected by an appeal to the reason of the person experience them.
• Delusions occur in clients with various types of psychotic disorders like cognitive impairment disorder and schizophrenic disorder.
Types of Delusions:
Delusion of reference or persecution – client believes that he or she is the object of environmental attention or is being singled out for harassment. “The police are watching my every move. They’re out to get me.”
Delusion of alien control – client believes his or her feelings, thoughts, impulses or actions are controlled by an external source. “A spaceman sends me messages by TV and tells e what to do.”
The Essay on Obsessive Compulsive Disorder And Memory Deficit
Obsessive Compulsive Disorder (OCD) is a mentally crippling anxiety disorder, which is defined by obsessive thoughts, images, or impulses that persist regardless of the person’s endeavors to defeat them (Gerrig & Zimbardo, 2010). Some common OCD experiences are: extreme checking, extreme cleaning, and any habit that is taken to the extreme; OCD can also include common phobias: to animals, ...
Nihilistic delusion – client denies reality or existence of self, part of self or some external object. “I have no head.”
Delusion of self-deprecation – client feels unworthy, ugly or sinful. “I don’t deserve to live. I’m so unworthy of your love.”
Delusion of Grandeur – client experiences exaggerated ideas of his or her importance or identity. “I am Napoleon!”
Somatic delusion – client entertains false beliefs pertaining to body image or body function. The client usually believes that she or he has cancer, leprosy or some other terminal illness.
Hallucinations
• Hallucinations are sensory perceptions that occur in the absence of an actual external stimulus.
• They are present in clients with substance related disorders, schizophrenia and manic disorders.
Types of Hallucinations:
Auditory Hallucination – client tells that he hears voices frequently while he sits in his lounge chair. “The voices tell me when to eat, dress and go to bed each night.”
Visual Hallucination – client describes seeing spiders and snakes on the ceiling of his room late one evening as you make rounds.
Olfactory Hallucination – client states she smells “rotten garbage” in her bedroom, although there is no evidence of any foul-smelling material.
Gustatory (Taste) Hallucination – client complains of a constant taste of salt water in her mouth.
Tactile Hallucination – clients undergoing symptoms of alcohol withdrawal and delirium tremens, complains of feeling “worms crawling all over body.”
Depersonalization
• Depersonalization refers to a feeling of unreality or strangeness concerning self, the environment or both. Example: clients have described out-of-body sensations in which they view themselves from a few feet overhead.
• These people may feel they are going crazy.
• Causes include prolonged stress and psychological fatigue and substance abuse.
• Common in schizo, bipolar disorder and depersonalization disorders.
Obsessions
• Obsessions are persistent thoughts, recognized as arising from the self, usually regarded by clients as absurd and relatively meaningless, yet persistent.
• Persons who experience obsessions describe them as “thoughts I can’t get rid of” or by saying “I can’t stop thinking of things……..they keep going on in my mind over and over again.”
• Typically seen with obsessive-compulsive disorders.
Compulsions
• Compulsions are insistent, repetitive, intrusive and unwanted urges to perform an act contrary to one’s voluntary wishes or standards.
• Example: client’s urges to gamble although his wife threatened to divorce him if he doesn’t stop playing poker. If a person does not engage in such activity, he usually experience anxiety and tension.
• Frequently seen in clients with obsessive-compulsive disorders.
6. ORIENTATION
• During assessment, clients are asked questions regarding their ability to grasp the significance of their environment, an existing situation or the clearness of conscious processes.
• They are oriented to person, place and time. Do they know where they are, who they are, what the date is?
Levels of Orientation and Consciousness:
Confusion – disorientation to person, place, or time characterized by bewilderment and complexity.
Clouding of Consciousness – disturbance in perception or thought that is slight to moderate in degree, usually owing to physical or chemical factors producing functional impairment of the cerebrum.
Stupor – a state in which the client does not react to or is unaware of the surroundings. The client may be motionless and mute, but conscious.
Delirium – confusion accompanied by altered or fluctuating consciousness. Disturbance in emotion, thought and perception is moderate to severe. Usually associated with infection, toxic states, head trauma and so forth.
Coma – loss of consciousness.
7. MEMORY
• The ability to recall the past experiences.
• Divided into recent and long term memory.
• Recent memory is the ability to recall events n the immediate past and up to 2 weeks previously.
• Long term memory is the ability to recall remote past experiences such as date and place of birth, names of schools attended and chronologic data relating to illnesses.
• Memory defects may result from lack of attention, difficulty with retention, difficulty with recall or a combination.
• Loss of recent memory may be seen in clients with dementia, delirium or depression.
• Long term memory loss usually is due to physiologic disorder resulting from brain dysfunction.
Three Disorders of Memory:
Hyperamnesia – abnormally pronounced memory.
Amnesia – loss of memory.
Paramnesia – falsification of memory.
Confabulation – filling in of memory gaps
Dementia – gradual deterioration of intellectual functioning resulting in the decreased ability to perform ADL
Déjà vu – feeling of having been to place which one has not yet visited.
Jamais vu – feeling of not having been to place which one has visited.
8. INTELLECTUAL ABILITY
• A person’s ability to use facts comprehensively is an indication of intellectual ability.
• During assessment, patient may be asked general information such as names of the last three presidents.
• He may also be asked to calculate simple arithmetic problems or form opinions concerning subjective matters.
• Example: “What would you do if you found a wallet in front of your house?
• Nurses evaluate reasoning ability and judgment by the response given. Abstract and concrete thinking abilities are evaluated by explanations of proverbs such as “an eye for an eye and a tooth for a tooth.”
9. INSIGHT REGARDING ILLNESS OR CONDITION
• Does the client consider him ill? Does the client understand what is happening? Is the illness threatening the client?
• Insight is defined as self-understanding or the extent of one understands about the origin, nature and mechanisms of one’s attitudes and behavior.
• Client’s insights into their illness ranges from poor to good.
• Insightful clients are able to identify strengths and weaknesses that may affect their response to treatment.
10. SPIRITUALITY
• Nurses must take a spiritual history and understand the client’s beliefs, values and religious culture because this will equip the nurse to evaluate whether these beliefs and values are helping or hindering them.
• Religious beliefs can be used by the client as their coping mechanism and to what extent religious or spiritual issues are pertinent to the client’s current situation.
11. SEXUALITY
• Does the client express any concerns regarding sexual identity, activity and function? When did these concerns begin? Does the client prefer male or female clinician to discuss these concerns?
• The age and sex of the clinician may affect the responses given.
• Example: A 50 year old male may feel uncomfortable discussing issues related to sexuality with a nurse who appears to be the same age as his daughter. A female client with the clinical symptoms of depression may be reluctant to discuss sexual abuse with a male nurse.
12. NEUROVEGITATIVE CHANGES
• Does the client exhibit changes psycho physiologic functions such as sleep patterns, eating patterns, energy levels, sexual functioning or bowel functioning?
• Depressed persons usually complain and manifest symptoms of insomnia or hypersomnia, loss of appetite or increased appetite, loss of energy, decreased libido and constipation.
• Psychotic may neglect their nutritional intake, appear fatigued, sleep excessively and ignore elimination habits (sometimes to the point of developing a fecal impaction).
Sleep Pattern
An often neglected but extremely valuable question to ask client is “Do you have difficulty sleeping at night or staying awake during the day?
Acute or Primary Insomnia – is often caused by emotional or physical discomfort like stress, hyperarousal, poor sleep hygiene, environmental noise or jet lag.
Secondary Insomnia – is related to psychiatric disorders like depression, anxiety or schizophrenia; general medical or neurologic disorders; pain or substance abuse.
Common Sleep Disorders:
Insomnia – difficulty initiating or maintaining sleep.
Jet Lag – 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.
Narcolepsy – overwhelmingly sleepiness in which the individual experiences irresistible attacks of refreshing sleep, cataplexy (loss of muscle tone) and/or hallucinations or sleep paralysis at the beginning or end of sleep episodes.
Nightmare disorder – repeated awakenings from the major sleep period or naps with detailed recall of extended and extremely frightening dreams, usually involving threats to survival, security or self-esteem.
Restless leg syndrome – characterized by insomnia associated with crawling sensations of the lower extremities; frequently associated with medical conditions such as arthritis or pregnancy.
Sleep apnea – a breathing-related sleep disorder due to disrupted ventilation or airway obstruction in which the individual may experience a lack of airflow. The normal sleeping pattern is completely disrupted several times throughout the night.
Sleep terror disorder – recurrent episodes of abrupt awakening from sleep usually accompanied with a panicky scream, intense fear, tachycardia, rapid breathing and diaphoresis. The individual is unresponsive to efforts of others to provide comfort and there is no detailed dream recall.
Enuresis – bedwetting
Bruxism – teeth grinding
Somniloquence – sleep talking
Somnambulism – sleep walking
13. MOTOR ACTIVITY
Echopraxia – imitation of actions/posture of others
Waxy flexibility – maintaining a desired position for long periods without discomfort
Akinesia – loss of movement
Bradykinesia – slowness of all voluntary movement including speech
Ataxia –loss of coordinated movement
DOCUMENTATION OF ASSESSMENT DATA______________________________
• Information obtained by the nurse during the assessment process is documented on the nursing admission-history form used by the specific psychiatric or mental heath facility. This information is significant in planning for treatment and disposition of clients.
• Documentation is important in research because it is an accurate record of the symptoms, behavior, treatment and reactions of the client.
• Documentation is recognized by legal authorities who frequently use the information for testimony in court.
Basic Criteria for Documentation:
Objective: what the client says and does by stating facts and quoting the client’s conversation.
Descriptive: describes the client’s appearance, behavior and conversation as seen and heard.
Complete: examinations, treatments, medications, therapies, nursing interventions and the client’s reaction. Samples of client’s writing or drawing should be preserved.
Legible: must be written legibly, with the use of acceptable abbreviations only and no erasures. Correct grammar and spelling are important and complete sentences should be used.
Dated: note the day and time of each entry.
Logical: should be presented in logical sequence.
Signed: form should be signed by the person making the entry.
