Psychiatric Assessment and Mental Health Nursing (Chapter 8)
Fundamentals of Effective Client Assessment
Requirement for Feedback
Effective assessment of a client or patient depends heavily on obtaining their feedback.
Vague responses or a lack of answers prevent the nurse from completing a proper and thorough assessment.
Participation is essential for knowing the patient’s full medical history.
Barriers to Communication
Willingness to Talk: Patients may simply not want to engage and might request to be left alone.
Depression: Severe depression can result in a patient withdrawing from communication.
Psychosis: Psychotic patients may lose the ability to answer questions or may not know the answers due to their mental state.
Alternative Assessment Strategies
Observations: The nurse relies on visual cues and behavioral monitoring.
Medical Records: Reviewing historical documentation is critical when the patient cannot provide a history.
Third-Party Input: Gathering information from family and friends. For example, when assessing a child, the mother’s presence and input are vital.
Factors Influencing Assessment Outcomes
Patient Health Status
Poor health, sickness, fatigue, or confusion can cause a patient to be short or uncooperative.
Patients may simply be too tired to participate in a lengthy assessment.
Previous Experiences and Misconceptions
Fear and Mistrust: Negative past experiences in the medical field can lead to a lack of trust.
Guardedness: Patients may be guarded or provide inappropriate answers to avoid being judged.
Health Literacy: Patients may not understand medical jargon. Nurses must adjust communication to a level the patient understands, often using real-life scenarios as analogies.
The Nurse's Attitude
Avoid being rushed, judgmental, or unprofessional.
Poor approach or using short, clipped questions can negatively influence responses.
Nurses must be aware of their own responses and recognize that communication is defined by how something is said rather than just what is said.
The Assessment Environment
The space must be private and quiet to respect confidentiality.
The environment must be comfortable and safe; a patient who feels unsafe will not share information.
Nurses must allow enough time for the patient to provide thorough answers.
Interview Techniques and Communication Styles
Closed-Ended Questions
Used for obtaining direct, specific answers, often "yes" or "no."
Examples: "Are you having pain?", "Did you take your medicine?", "Did you sleep okay last night?"
Open-Ended Questions
Statements or questions designed to elicit more broad and detailed information.
These help build rapport and a therapeutic relationship while allowing the patient to express themselves.
Examples: "Tell me about how your relationship is.", "Tell me what brought you in today.", "What can I do to help you today?", "How have you been dealing with this?"
Professional Conduct in Communication
Use a calm, neutral tone at all times.
Ask sensitive questions (e.g., sexual orientation regarding being straight, gay, lesbian, or trans) in a matter-of-fact manner.
Avoid judgmental words or facial reactions (e.g., shock regarding histories of abortion or sex work).
Phrasing Example: Instead of asking "How do you physically punish your child?" (judgmental), ask "What type of discipline do you use with your children?" (non-judgmental).
Components of the Psychosocial Assessment
Assessment Robustness
A full psychiatric assessment typically takes approximately hour to complete.
Nurses should be able to gather initial data through quick questioning during regular interactions.
Core Categories of Assessment
History: Includes both family medical history and the patient's individual medical/surgical history.
General Appearance: Observations of dress, grooming, hygiene, and eye contact.
Motor Behavior: Checking for extra movements, tics, tremors, or an abnormal gait.
Mood and Effect: Internal emotional state versus external expression.
Thought Process and Content: Identifying how the patient thinks and what they are thinking about.
Intellectual Process: Includes concentration, memory, and cognitive abilities.
Judgment and Insight: The ability to make decisions and the understanding of one's own illness.
Self-Concept: The patient's view of themselves.
Roles and Relationships: How they interact with others.
Physiological and Self-Care Concerns: Monitoring basics like bathing, eating, and sleep.
Detailed Breakdown: Mood and Effect
Definitions
Mood: The internal emotional state or how someone feels inside.
Effect (Affect): The outward, visible expression of emotion.
Assessment Criteria
The nurse assesses consistency between the patient’s statements and their body language.
Example: A patient saying "I'm fine" while looking down and speaking slowly suggests a discrepancy.
Classification of Effect
Broad Effect: A full range of emotional expression, whether appropriate or not.
Inappropriate Effect: The emotional expression does not match the situation (e.g., laughing when discussing the death of a loved one).
Restricted Effect: A serious or somber expression; lack of variety in expression.
Blunted Effect: Slow response, minimal eye contact, quiet speech, low tone, and flat delivery.
Flat Effect: Absolute lack of emotional or facial expression.
Detailed Breakdown: Thought Process and Content
Comparison: The Train Analogy
Thought Process: The "train tracks"; the path or flow of thinking. Is it straight and logical or jumbled?
Thought Content: The "cargo inside the train"; the actual material or subjects the person is thinking about.
Types of Thought Processes
Circumstantial Thinking: Beating around the bush or giving excessive detail but eventually returning to the original point.
Tangential Thinking: The speaker goes off-track and never returns to the original question or topic.
Loose Associations: Disorganized, illogical thoughts with very little or no connection between themes.
Flight of Ideas: Rapidly shifting speech where the patient moves through multiple unrelated stories or topics very quickly.
Word Salad: A jumble of words that have no meaning together (e.g., "I jumbled, walked over the whatever").
Thought Blocking: Suddenly stopping a train of thought mid-sentence.
Types of Thought Content
Delusion: A fixed, false belief that cannot be changed by logic or evidence (e.g., believing one is a king, princess, or the president, or believing aliens are outside).
Ideas of Reference: The belief that external events (TV, radio, street signs) have a direct, personal message specifically for them.
Thought Broadcasting: The belief that others can hear or read the patient's thoughts.
Thought Insertion: The belief that others are putting thoughts into the patient's head or brainwashing them.
Thought Withdrawal: The belief that thoughts are being removed from the patient's mind.
Grandiosity: Periods where the patient believes they are better than everyone else.
Safety Assessment and Legal Obligations
Assessing Risk
Nurses must determine if there is a risk of the patient harming themselves or others.
Evaluation includes motive, plan, and access to means.
Breach of Confidentiality
Duty to Warn: Nurses have a legal obligation to warn a threatened person if the patient makes statements involving an identifiable victim and a specific plan.
Involuntary commitment may be necessary if the patient is a danger to themselves or others.
Suicide risk must be assessed via questions regarding ideation (current or past), specific plans, access to methods, and the where/when/time of the planned act.
Cognitive and Intellectual Functioning
Orientation
Nurses check for awareness of Person, Place, Time, and Situation (e.g., "Who are you?", "Where are you?", "Who is the president?").
Memory Assessment
Immediate/Recent/Short-term: Asking the patient to recall three words (e.g., cat, can, car) or asking what they ate for breakfast.
Remote/Long-term: Asking about childhood details or a social security number.
Concentration
Serial Sevens: Asking the patient to count backward from by ().
Reverse Spelling: Having the patient spell a word backward.
Three-step Command: Asking the patient to follow a sequence of three instructions.
Abstract vs. Concrete Thinking
Abstract Thinking: Looking beyond the obvious to interpret deeper meanings. For example, interpreting "A stitch in time saves nine" as meaning a small fix now prevents a bigger problem later.
Concrete Thinking: Literal interpretation. A concrete thinker would interpret "Don't cry over spilled milk" as literally meaning you shouldn't cry when milk spills on the floor.
Painting Analogy: Abstract thinking is like free-hand painting; concrete thinking is like painting by numbers.
Sensory Perception
Hallucinations: Sensory experiences (visual, auditory, olfactory, tactile, gustatory) that occur without an external stimulus (e.g., hearing voices or seeing things not there).
Judgment vs. Insight
Judgment
Refers to the ability to interpret the environment and make appropriate decisions or behaviors.
The Steering Wheel Analogy: Deciding which way to go or how to react to a situation (e.g., what to do if you smell smoke or find a stamped envelope on the ground).
Insight
The understanding of one's own situation, illness, and the need for treatment.
The Dashboard Analogy: Understanding the internal state and accepting personal responsibility for health and behaviors.
Physiological and Professional Considerations
Self-Care and Physiological Needs
Assessment includes checking basic physical needs, hygiene, and medication compliance.
Nurses must identify barriers such as lack of transportation or financial difficulties.
Monitoring substances used and overall health patterns.
Data Analysis and Diagnostics
Nurses must gather information, identify cues/patterns, and prioritize problems to create a holistic plan.
Assessment is an ongoing, dynamic process that can change from hour to hour.
The DSM-5-TR
Full Title: Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision.
Function: Classifies mental health disorders, provides diagnostic criteria, and describes behaviors associated with specific disorders.