Chp.11 Psychiatric mental health nursing process

What are some techniques from data collection?

• Patient observations: What are you noticing about the patient  

• Interviews 

  • Patient and family. and any other support system, especially if patients are unable to give information.

• Physical exam: lab workups

• Records and diagnostic reports: school reports, charts.

• Collaboration with colleagues: social work, case workers, counseling, other nurses, and providers.

What are we looking for in a biological and physical assesment?

• Current and past health status:

  • Looking a family history 

  • What conditions or illnesses have they had 

  • Any surgeries 

  • Life-changing events

• Physical examination 

  • Body systems review 

  • Neurologic status 

  • Laboratory results

  • physical function: overall health

What are we looking for in a Pharmacological assessment?

What are they taking and why?

What are we assessing in a psychological assessment?

• Mental Status Exam (MSE)

• Behavior: what are they doing, how are they acting.

• Self-concept

  • Body image- how they view themselves

  • Self-esteem- low or high?

  • Personal identity- who are you

• Stress and coping patterns- how do you cope?

• Risk Assessment

  • Self- are they a danger to themselves

  • Others

During a MSE what are we looking for in general observation/apperance?

• Hygiene, clothing: the condition of it- appropriate clothing for the situation.

• What they are wearing, how they are wearing it.

• Do they look their age.

In a MSE what are we look for in Behavior/attitude/cooperation?

• Behavior/Attitude/Cooperation

  • restless, agitated, ticks, trimmers

  • trustful, guarded, withdrawn

  • are they answering our questions

MSE speech assessment?

• Volume: mumbled, loud

• Rate: slowed, pressured

• Quality: can they anunciate

MSE thought process?

• The way they think.

  • Normal thinking: logical, focused, congruent 

what is circumstantial thinking?

• Ex: are you hungry?

  • They get to the point eventually, but before they give unnecessary information before the answer.

What is Tangential thinking/

• go on tangents, and don’t answer the question.

what is an incoherent thought process?

• doesn’t make any kind of sense.

MSE thought content?

• assesing what someone is thinking about.

• suicidal and homicidal thoughts

Suicidal assessment questions ( MSE)?

• Have you ever thought about hurting yourself?

• Do you have a plan?

• Is it tangible?

• When? and Where?

• Is it reversible?

• Can they commit to safety?- If they are in imminent danger, do not leave them.

Homicidal assessment questions? (MSE)

• Have you ever thought about hurting someone else?

• Do you have a plan? When? Where? who?

• Is it serious? “ duty to warn”

MSE delusions assesment?

• Do you feel like someone is out to get you?

• Do you have any special powers?

• Grandiose: false, exaggerated beliefs of ones own importance, special powers, or high status.

MSE mood/ affect assessment?

• Happy and sad when you should be.

• Euthymic: normal mood 

  • Disthymic: bad mood, depressed- will have a flat affect.

  • Euphoric: always happy, seen alot with mania.

  • Labile mood: up and down all the time. 

• affect: able to cry, smile, etc.

• asses the congruency of their mood and affect.

MSE perceptions?

• Record hallucination 

  • Tactical hallucination: feeling things that aren’t there.

  • Auditory: Do you hear something that others can’t hear?

  • Visual: seeing things that aren’t there.

  • illusion: when you see something, but you're misinterpreting it.

MSE insight and judgement assesment?

• Insight:

  • What brought you to the hospital? Why are you here? trying to see if they know what's going on.

• Judgment:

  • making decisions they shouldn’t be. Assessing decision-making ability.

MSE sensorium/cognition assessment?

• A&O

• Cognition:

  • Attention: good or poor?

  • Following you, answering questions, and engaging.

  • Serial 7, spelling word backwards.

  • Abstract thinking: 

    • “Have you ever heard the saying, Don’t cry over spilled milk”

    • Yes, it means don’t cry over small things 

  • Concrete: 

    • If it's in the kitchen and on tail you can just clean it up.

  • Need to know so you know how to give them information 

MSE memory assessment?

• Short-term: give them three words and then ask from them after a few minutes

• lOng-term.

  • Ask them where they were born.

Social assessment: functional status and social systems?

• Functional Status: ADLS,

• Social Systems

  • Family assessment: Who are the members of their family? Their role?

  • Cultural assessment: Do you identify with a specific culture?

  • Community support and resources: Do you have the things you need?

Social assessment: occupational status? economic status?

• Occupational Status:

  • Do you have a Job?

  • How long have you been employed?

  • Meaningful fit?

• Economic Status

  • Are they able to make ends meet?

  • Can they buy the things they need?

  • Can you afford your medications?

social status: legal status? quality of life?

• Legal Status:

  • Criminal record? What happened?

• Quality of Life:

  • How they perceive it.

social assessment: psychosocial strengths/ weaknesses?

• Help the patient identify their strengths  and weaknesses

what are some questions to ask for spirituality?

What gives you life meaning? Purpose of life? Can you forgive others and yourself? Do you believe in God or a higher power?

How can we identify problems and needs of our patients?

• Cluster assessment data

• With patient, identify immediate health care needs/ problems

• Prioritize health care problems

• Safety needs are always priority

what are some nursing interventions to promote physical health?

• Promotion of self-care activities

• Activity and exercise 

• Sleep

• Nutrition

• Relaxation

• Hydration

• Thermoregulations

• Pain management

• Medication management

What are some nursing interventiosn to promote psychological health?

• Counseling

• Conflict resolution

• Bibliotherapy

• Reminiscence

• Cognitive/Behavioral therapy

• Psychoeducation

• Health teaching

what are some nursing interventions to promote social health?

• Social behavior/ privilege systems- 

• Milieu therapy- using patient environment

  • Containment

  • Validation

  • Structured interaction

  • Open communication

• Promotion of patient safety

• Home visits

• Community action