Psychitaric Nursing Assessment

Assessment

Collect and organize pt data

Nursing Diagnosis

• Identify pt problems

• Prioritize

Outcome identification/planning

• Determine strategies to meet goals

• Collaborate with the interdisciplinary team

• Develop measurable, time bound goals

Implementation

Carry out planned interventions

Evaluation

• Determine whether goals were met

• Revise plan as needed

Assessment with psych patients

Patients are considered primary sources and collateral (others) are secondary sources

Objective data for psych pts

Directly observed or backed by a tool

• Vitals

• Labs

• MSE

• screening tools (AIMS, SLUMS, PHQ-9, etc)

Subjective data for psych pts

Data given to you by others

• History

• Psychosocial

• ROS

• Self awareness assessment

• Validating assessment

Psych nursing assessment goals

• Establish rapport

• Obtain understanding of chief complaint

• Review physical status and VS

• Assess for safety risk factors

• Assess mental status

• Identify mutual goals for treatment

Things included in physical status of a psych pt

• Current VS (include height and weight)

• Obtain medical history and ROS (same as head to toe exam)

• Ask about medications

• Review ordered labs

Chief complaint

Reason for the or to visit, record as direct quote from pt

History of present illness

History of events leading to visit including patients own description of symptoms

Psychiatric history

History of diagnoses, suicide attempts, trauma, inpatient hospitalizations, meds, outpatient services

Substance abuse history

Get complete history including quantities and amount of use

Family mental health history

primarily care about last 3 generations

Mental status exam

Evaluates a patients current cognitive functioning and thought processes as observed at the time of assessment

• conducted upon admission and each shift

what to assess in a MSE

All - appearance

Borderline - behavior (mood)

Subjects - speech

Are - affect

Tough - thought processes

Troubled - thought content

Characters - cognitive exam

What to include when looking at appearance

• general appearance ( appeared age, notable weight, skin markings)

• Grooming and hygiene (poor, appropriate, odor, disheveled)

• Clothes (clean/dirty, appropriate for age or weather)

Mood is …. Reported

Self

Euthymic

Normal display of emotion

Labile

Moody, moods shift quickly

What to observe in terms of speech

• Articulation/clarity

• Volume

• Rate

• Pressured speech

• Tone

• Rhythm

• Quantity

Affect

Your perception of the pt mood

In terms of affect, assess for the following 4 things

1. Emotional state (quality) - dysphoric, euthymic, anxious, etc.

2. Range (variability) - full range, constricted blunted, labile

3. Appropriateness

4. Congruence - affect aligns with stated mood

5 types of thought processes

1. Circumstantial

2. Tangential

3. Loose associations

4. Word salad

5. Flight of ideas

Circumstantial thought process

Will eventually answer queestion, but gives lots of unnecessary detail

Tangential

Will give lots of detail and not answer question

Loos associations thought process

No logical connection between ideas, sever disorganization

• common in dementia, psychosis, manic

  
  

Word salad thought processes Troubled

Jumbled nonsensical mix of words, with complete disorganization

Flight of ideas thought process

Never done back to question and rapid tractions loose associations

Thought blocking

Characterized by speech latency and can be a sign of depression, auditory hallucinations or avoidance behavior

Neologisms

Word or phrase or action that has not meaning for anyone but the pt

Echolalia

Repetition of another persons spoken words

• often seen in autism and schizophrenia

Catatonia

Lengthy speech latency where they may be standing or sitting in one once for hours

Different kinds of thought content for psych pts

• appropriate

• Obsessions

• Compulsions

• Suicidal ideation

• Homicidal ideation

Hallucinations

Sensory perceptions for which no external stimulus exists

4 types of hallucinations

1. Visual

2. Auditory

3. Tactile

4. Olfactory

Delusions

False fixed beliefs that cannot be corrected by reasoning

Paranoid

Belief that others are persecuting, oppressing, or intending to cause harm

Grandiose

Belief that one is exceptionally special or possesses unique powers, talents, or abilities

Religious delusions

Belief that a divine or supernatural event is occurring to oneself, family, or environment

Thought broadcasting

Belief that one’s thoughts are accessible to or can be heard by others

Thought insertion

Belief that external forces are placing thoughts into one’s minds

Thought of being controlled

Belief that one’s thoughts, feelings, or actions are being controlled by outside people or forces

Illusions

Sensory distortion or misperception of an actual stimulus usually caused by an underlying medical etiology

The nurse observes the pt with schizophrenia to be speaking monotonously without facial expressions. Which term does the nurse use to document this finding?

Flat affect

A pt reports insects crawling on their skin. What type of hallucination is this an example of?

Tactile

LOA

Level of alertness; can use Glasgow coma scale, orientation, and do they appear alert or sleepy

5 parts of a cognitive exam

1. LOA

2. Attention

3. Memory

4. Judgment

5. Insight

Mini mental cognitive exam (mini-cog)

Used to asses cognitive decline in dementia

What does the mini-cog test include

• three item recall (1 point for each correct word)

• Clock drawing (1 point for accurate clock, 1 point for correct time)

On the mini-cog, what score is indicative of a positive screen for dementia

3 or less

St. Louis university mental status (SLUMS)

• 3 orientation questions

• 5 object recall

• Simple math question

• Timed animal name recall

• Digit span test

• Clock drawing

• Shape recognition

• Short narrative

10 parts of psychosocial questions to ask a pt

1. Development history

2. Family life

3. Education

4. Work

5. Finances

6. Relationships

7. Activities

8. Military

9. Religious

10. Cultural

HEADSSS psychosocial interview technique

H - home environment

E - education and employment

A - activities

D - drug, alcohol, or tobacco use

S - sexuality

S - suicide risk or symptoms of depression

S - savargery (violence/abuse)

useful tools to stay organized in documentation of MH

• SOAPE (subjective, objective, assessment, plan, evaluation)

• SBAR