Chapter 7: The Nursing Process and Standards of Care

what is the name of the psychosocial interview technique used for adolescents?

HEADSSS

what does HEADSSS stand for?

Home environment, Education and employment, Activities, Drug, Sexuality, Suicide risk, Safety

In a mental status examination what is being assessed with appearance?

grooming and dress, level of hygiene, pupil dilation or constriction, facial expression, height, weight, nutritional status

In a mental status examination what is being assessed with behavior?

excess or reduced body movements, peculiar body movements, abnormal movements, level of eye contact

In a mental status examination what is being assessed with speech?

rate, volume, disturbances

In a mental status examination what is being assessed with mood?

affect, mood

In a mental status examination what is being assessed with disorders of the form of thought?

thought process, thought contact

In a mental status examination what is being assessed with perceptual disturbances?

hallucinations, illusions

In a mental status examination what is being assessed with cognition?

orientation, level of consciousness, memory, fund of knowledge, attention, abstraction, insight, judgement

In a mental status examination what is being assessed with ideas of harming self or others?

suicidal or homicidal history, presence of a plan, means to carry out the plan, opportunity to carry out the plan

psychosocial assessment for previous hospitalization, education and occupational background?

employed? where? what length of time? special skills

psychosocial assessment for social patterns?

describe family, friends, household members, support system, describe a typical day

psychosocial assessment for sexual patterns?

sexually active? safe sex? birth control? sexual orientation, sexual difficulties

psychosocial assessment for interests

how do you spend your spare time? interest in sports, hobbies, or leisure activities?

psychosocial assessment for substance use?

prescribed medications? OTC drugs? recreation? how often? how much?

psychosocial assessment for coping abilities?

what do they do when upset? who can they talk to? previous coping mechanisms before therapy?

psychosocial assessment for spiritual assessment?

importance of religion or spirituality? does faith help relieve stress?

psychosocial assessment for health behaviors?

who do they see when medically ill? special healthcare practices?

what standardized rating scales are used for major depressive disorder?

Beck Inventory, Brief PHQ, GDS, Hamilton Depression Scale, Zung Self-Report Inventory, PHQ-9, PHQ-A

what standardized rating scales are used for anxiety?

Brief PHQ, GAD-7, Modified Spielberger State Anxiety Scale, Hamilton Anxiety Scale, Severity measure for GAD Child (11-17)

what standardized rating scales are used for trauma?

adverse childhood experiences questionnaire, brief trauma questionnaire, CAPS-5, PSS-I & PSS-I-5

what standardized rating scales are used for substance use disorders?

ASI, RAATE, B-DAST

what standardized rating scales are used for obsessive-compulsive behavior?

Yale Brown Obsessive-Compulsive scale (Y-BOCS)

what standardized rating scales are used for mania?

mania rating scale

what standardized rating scales are used for schizophrenia?

SANS, BPRS

what standardized rating scales are used for abnormal movements?

AIMS, Simpson Neurological Rating Scale

what standardized rating scales are used for general psychiatric assessment?

BPRS, GAF

what standardized rating scales are used for cognitive function?

MMSE, SLUMS, CCSE, ADRS, Memory and Behavior problem checklist, FAST, GDS

what standardized rating scales are used for family assessment?

McMaster Family Assessment Device

what standardized rating scales are used for Eating disorders?

EDI, body attitude test, diagnostic surgery for eating disorders