Study Notes on Nursing Assessment in Psychiatry

Introduction to Nursing Assessment in Psychiatry

• All nurses conduct assessments for patient care.

• Assessments involve meeting the patient, asking questions, and collecting data to guide care.

Types of Assessments

• Psychosocial Assessment:

  • Also known as a bio-psychosocial assessment which includes:

  • A mental status exam.

• Purpose: To construct a picture of the patient's emotional state, assess mental capacity and behavioral function, identify cues that require action, and establish a baseline for treatment evaluation.

Elements Influencing Assessment

• Patient participation is crucial for the assessment to be useful.

• Influencing factors include:

  • Health status of the patient.

  • Previous experiences or misconceptions about healthcare.

  • Patient's ability to understand the assessment.

  • Nurse's attitude toward the patient.

• Majority (70%) of patients may engage in the assessment process.

• Challenges arise as:

  • In psychiatric assessments, some patients may be unable or unwilling to answer questions due to their condition.

  • Documentation is important for patients unable to provide history (considered "not a reliable historian").

Factors Affecting Assessment Quality

• Health Status:

  • Anxiety, tiredness, or pain can distort responses.

  • Anxiety is often a baseline emotional state for psychiatric patients.

• Patient Medications:

  • Administer medications to de-escalate anxiety before assessments to encourage participation.

• Prior Experiences with Healthcare:

  • Understand likely mistrust or fear based on previous negative experiences (often a factor with repeat admissions).

• Communication Barriers:

  • Assess barriers such as hearing or cognitive impairments and document them.

Effective Communication Techniques

• Approach should be nurturing and self-aware.

• Utilizing open-ended questions provides opportunities for detailed answers.

• Closed-ended questions may be required for sensitive topics (e.g., suicidal thoughts).

• Establish a therapeutic relationship quickly.

• Sensitive topics should be asked gently to avoid creating defensiveness.

Safety in Patient Interactions

• Ensure the environment is safe and conducive to communication.

• Avoid isolated locations, particularly with patients with a history of threatening behavior.

• Engage with family for collateral history to enrich the assessment process:

  • Helpful for patients who are depressed, psychotic, or unable to provide history.

• Conduct separate interviews when necessary to gather information without distressing patients or influencing their responses.

Questioning Techniques for Assessment

• The balance of open-ended and closed-ended questions:

  • Open-ended: "What brings you in today?"

  • Closed-ended: "Have you had any suicidal thoughts?"
    \n# Establishing Patient Mood and Affect

• Distinguish between mood (patient's consistent emotional state) and affect (observable emotional state).

• Assess for congruence: are mood and affect consistent with each other?

  • Example: Anxious demeanor with claims of confidence signifies incongruence.

Observing Behavior and Motor Skills

• Document appearance using appropriate terminology (e.g., "unkempt" rather than harsh descriptions).

• Observe posture, eye contact, and any unusual movements or behaviors.

  • Signs of anxiety (e.g., tapping feet, picking skin).

  • Psychomotor retardation often seen in severe depression.

Specific Signs of Psychiatric Conditions

• Affect Types:

  • Broad affect: full emotional expression.

  • Flat affect: lack of emotional expression.

  • Restricted affect: limited emotional expression.

  • Inappropriate affect: emotional response does not fit the situation.

  • Waxy flexibility: maintaining unnatural postures.

Thought Processes and Content During Assessment

• Assessment of thought content:

  • Delusions: fixed false beliefs (e.g., paranoid delusions).

  • Tangential thinking: stories that veer off-topic without returning.

  • Pressured speech: rapid, loud talking indicative of mania.

  • Flight of ideas: rapid shifts between topics during conversation.

• Assessing risk of harm:

  • Utilize direct questioning to gauge suicidal ideation, plans, or thoughts of self-harm or harm to others.

Cognitive Assessment Techniques

• Assess mental orientation:

  • A&O x 4: awareness of person, place, time, and situation.

  • Execute memory tests (e.g., recent and remote memory).

• Assess concentration abilities through tasks like spelling or serial counting.

  • Evaluate abstract vs. concrete thinking abilities with proverbs or similar tasks.

Conclusion

• Proper assessment requires a blend of observational skills, appropriate questioning, and an understanding of the patient's unique context.

• Continuously adapt techniques to ensure a thorough, sensitive, and effective assessment process while keeping in mind the therapeutic relationship and safety.