Client Response to Illness and Mental Health Assessment

Individual Factors Affecting Response to Illness

  • Age, Growth, and Development:

    • Based on Erik Erikson's psychosocial stages of development.
    • Consider if a patient missed a stage; compensate accordingly (e.g., building trust with a patient who didn't learn it as an infant).

  • Biologic and Genetic Factors:

    • Factors beyond voluntary control.

  • Physical Health and Health Practices:

    • Healthier individuals cope better with stress.
    • Mental illness and crisis are stressful.

  • Response to Drugs:

    • Varying rates of metabolism among individuals; older adults often metabolize drugs slower.
    • Smaller doses and longer intervals may be necessary.

  • Self-Efficacy:

    • The belief that one's actions make a difference in their health.
    • Based on past difficult experiences.
    • Affected by social persuasion and modeling.
    • Involves stress reduction, physical strength, and positive interpretation of physical sensations.

  • Hardiness:

    • Ability to resist illness under stress.
    • Three components:
      • Commitment: Active engagement.
      • Control: Ability to make decisions.
      • Challenge: Perceiving change as beneficial and a way to grow.

  • Resilience:

    • Healthy response to situations using problem-solving abilities.
    • Ability to cope with adverse situations.
    • High resilience observed in US Army Reserve and National Guard soldiers.

  • Spirituality:

    • Addresses meaning of life and purpose.
    • Provides support and solace in coping with stress and illness.
    • Requires sensitivity to client's beliefs and practices.

Interpersonal Factors Affecting Response to Illness

  • Sense of Belonging:

    • Connectedness within social systems and the environment, including family and friends.
    • Helps individuals cope better.

  • Family Support:

    • Meaningful relationships improve health and well-being.
    • Effectiveness depends on the person's willingness to accept help and trust their family.

Cultural Factors Affecting Response to Illness

  • Beliefs About the Cause of Illness:

    • Natural causes: E.g., too much cold or heat.
    • Unnatural causes: E.g., supernatural forces or punishment from a deity.

  • Communication:

    • Use approved translators for clients who prefer another language.
    • Speak directly to the client, maintaining eye contact, and allow time for translation.
    • Document translator use including their number.
    • Example of using translator when administering medication and assessing a Vietnamese speaking patient.
    • Importance of using a translator even if the doctor is busy.
    • Example of using translator when removing sutures from a deep wound.

  • Physical Distance:

    • Maintain appropriate physical distance, especially with mental health clients, to avoid triggering feelings of aggression or past abuse.
    • A distance of six feet is generally recommended.

  • Positioning:

    • Use a non-confrontational stance by turning slightly to the side with arms at your sides and one foot behind the other.
    • Allows for a quick exit if the situation escalates.
    • Ensure a safe environment by positioning yourself closest to the door.
    • May be helpful to leave the door slightly open.

  • Social Organization:

    • Consider the client's role in their family and how their illness impacts it.
    • Worries about family can affect healing and self-care.

  • Religious Beliefs and Values:

    • Recognize and respect patient's religious beliefs.

  • Ethnicity vs. Culture:

    • Ethnicity: What you're born with (genetic and geographical).
    • Culture: How you're raised, traditions.
    • Example: A baby born in China and adopted by an American family is ethnically Chinese but culturally American.
    • Ask the client about their cultural practices and beliefs to avoid assumptions.

  • Time Orientation:

    • Varies across cultures.
    • Some cultures value punctuality, while others have a more relaxed approach to time.
    • Individual families also have different views of time.
    • Example: In a pain clinic, staff allowed for time differences with a client from a different culture.

  • Environmental Control:

    • Adjust room temperature for patients who believe natural causes (e.g., being too hot or cold) cause illness.

  • Biologic Variations:

    • Some ethnicities have inherent predispositions to certain disorders.
    • Example: Sickle cell anemia.
    • Some blood pressure medications may not work for people of certain ethnic backgrounds.

  • Socioeconomic Status and Social Class:

    • Income can cause health disparities.
    • Education affects health literacy.
    • Occupation impacts security and stability.

  • Cultural Patterns and Differences:

    • Questions to ask:
      • How would you like to be cared for?
      • What do you expect or want me to do for you?
      • Do you follow any dietary preferences or restrictions?
      • How can I assist you in practicing your religious or spiritual beliefs?
      • How do you think this health problem came about?
      • What kinds of remedies have you tried at home?

  • Assessment:

    • Always ask about cultural factors and never assume.
    • The client is the best source of information.
    • Use an open and objective approach; be non-judgmental.
    • Use therapeutic communication techniques to encourage sharing.

Mental Status Examination (MSE)

  • Adding a mental health component to the nursing assessment.
  • Relies on client cooperation but can be adapted when cooperation is limited.
  • Use of quotations in documentation to capture the client's expressions and thoughts.
  • Previous documentation (ED, doctor's notes) can provide insights if client is uncooperative.
  • If the patient can't sit for the assessment, ask a few questions at a time.
  • Consider the client's physical health and how it affects the psychosocial assessment, aligning with Maslow's hierarchy of needs.
  • Address physical needs (e.g., alcohol withdrawal, coldness) before beginning the assessment.
  • Previous negative experiences can make them guarded during the assessment.
  • Ensure sensory abilities (hearing and seeing) and provide assistance if needed
  • Non-judgmental, encouraging attitude and therapeutic active listening are essential.
Video Example

  • A helpful interaction between a therapist who is assessing a teenager.

  • The therapist makes sure the client understand his right to privacy and confidentiality.

  • Key Observations:

    • Patient slowly warms up.
    • Therapist uses eye contact and jots down notes.
    • Therapist reflects back what client said.
    • Therapist sits with the awkward silences.
    • The interviewer asked why, which didn't work and quickly changes the approach.
Privacy Considerations
  • Environment should be comfortable and safe.
  • Involve family and friends with client permission.
  • Privacy policy and code system used on the floor.
  • Can't give family information without client's release of information.
  • If someone has a warrant out, the mental health hospital is a safe environment, so we do not tell the police they are in the hospital.
  • A missing person's case might be different when the police ask.
Phrasing Questions
  • Use open-ended questions for detailed information.
  • Use closed-ended questions for anxious or depressed clients.
General Framework for MSE
  • Use framework to ensure proper questioning.
  • History: Age, ID band (verify spelling/birth date).
Observations

  1. General Appearance and Motor Behavior:

    • Dress, hygiene, grooming.
    • Automatisms: Nervous movements (finger drumming, knee bouncing).
    • Psychomotor retardation: Slowed movements.
    • Waxy flexibility: Maintaining the same position.

  2. Mood and Affect:

    • Mood: Emotional state.
    • Affect: Outward expression of mood (facial expressions).
      • Flat affect: No facial expression.
      • Inappropriate affect: Laughing at something not funny.

  3. Thought Process and Content:

    • These are different definitions of things that you would notice in someone with schizophrenia.
    • Circumstantial Thinking: Unnecessary details before answering.
    • Delusion: Fixed false belief not based in reality.
    • Flight of Ideas: Rapid shift from one idea to another (mania).
    • Ideas of Reference: Type of delusion, they refer everything to themselves.
    • Loose Association: Disorganized thoughts jumping from one idea to another.
    • Word Salad: Jumbled words.
    • Neologisms: Made up words.
    • Tangential Thinking: Getting off on a tangent and not coming back to the question.
    • Thought Blocking: Stopping in the middle of a sentence.
    • Thought Broadcasting: Belief that others can read thoughts.
    • Thought Insertion: Belief that others insert thoughts into the brain.
    • Thought Withdrawal: Belief that others take thoughts away.

  4. Suicidal/Homicidal Ideations:

    • Assess for thoughts of self-harm or harming others.
    • Ask about past attempts and current plans.

  5. Sensorium and Intellectual Processes:

    • Orientation: Person, place, time, situation.
    • Memory: Assess recent memory (e.g., three-word recall).
    • Concentration: Spell a word backward, count backward by fives.
    • Abstract Thinking: Interpret proverbs (e.g., "The grass is greener on the other side").
      • Literal thinking: Concrete thinking.
      • Abstract thinking: Recognize the real meaning.
    • Sensory-Perceptual Alterations: Hallucinations (auditory, visual, tactile)

  6. Judgment and Insight:

    • Judgment: Ability to adapt behavior and decisions to the environment.
    • Insight: Ability to understand the true nature of the situation and accept responsibility.

  7. Self-Concept:

    • Self-worth, body image, confidence.

  8. Roles and Relationships:

    • Role in the family/satisfaction/anxiety.

  9. Physiologic and Self-Care Concerns:

    • Health status, allergies, medications, substance use (alcohol, nicotine).
Synthesis
  • Use information for nursing process/care plans.
  • Consider potential biases in psychological tests.
  • Psychiatrist/Practitioner diagnose using DSM-5 criteria.
  • MSE assesses current mental status.
  • Mini Mental State Exam (MMSE) is for dementia assessment.