Laurence L.

Garcia

 Referred to as psychosocial assessment psychiatric mental health nursing

in

Construct a picture of the clients current emotional state, mental capacity and behavioral function

 Client participation and feedback Clients health status Clients previous experiences / misconceptions about health care Clients ability to understand Nurses attitude and approach

ENVIRONMENT Comfortable, private, safe for client and nurse Fairly quiet with few distractions Isolated location

INPUT FROM FAMILY AND FRIENDS May limit the amount of information obtained The nurse must conduct at least part of the assessment without others Make effort to assess client in privacy in cases of suspected abuse

HOW TO PHRASE QUESTIONS Use open-ended questions Use direct questions if client cannot organize thoughts Use nonjudgmental tone and language

Phases: Opening phase warm up, establish rapport, prepare the patient for the main task Middle phase Screening of the problems: chief complaints, symptoms, severity, course, stressors Follow up of preliminary impressions History: longitudinal course, premorbid personality and social history, family history, medical history End phase : prepare patient for closure Feedback Treatment contract

- how the interviewer and his patient relate

HOW TO ESTABLISH RAPPORT

1. Put the patient and yourself at ease Small talk Recognize the signs: territorial (movement in the new territory), behavioral, emotional (posture, facial expression, gestures, eye contact, tone of voice), verbal (vocabulary and metaphors) Respond to signs: verbal, gestures

2. Find the suffering

Show compassion: facts, associated emotions Assess the suffering: ventilate suffering, focus on the patient and the pain Respond with empathy: genuine, spontaneous, accurate 3. Assess insight Become an ally Levels of insight Full Partial None Split off the sick: find the well part Set the therapeutic goal goals discussed with the patient therapeutic goals

4. Show expertise Put the illness into perspective Show knowledge: probe for specific symptoms; stir curiosity Deal with distrust: counter questioning, confrontation or interpretation 5. Establish authority: ability to handle the patient Authoritarian Facilitative/supportive

6. Balance roles The empathic listener patient is at ease sensitive to the patients suffering express compassion The expert: imparts know - how The authority: expects the patient to follow Carrier of an illness: patient views self as temporarily impaired and puts distance between himself and the disorder The sufferer consumed by pain and guilt craves comfort, understanding and sympathy Forces the nurse to set firm limit The VIP: privileged, entitled to attention at any time of the day Role interaction: monitor emerging roles and react accordingly Dependence on the interviewers authority

1. Complaints (Pouring out) Opening techniques: broad open ended; closed ended Clarification techniques Specification Generalization Checking symptoms Probing Interrelation Summarizing Steering techniques Continuation (general lead) Echoing (reflecting) Curbing (refocusing) Transitions: smooth, accentuated, abrupt

2. Dealing with resistance (revealing some and concealing embarrassing items) Acceptance: expression of understanding Confrontation: focus patients attention on the resistance Looping: approach the problem from a different angle Exaggeration: decrease patients concern by putting it into perspective Induction to bragging: patient making good impressions

3. Defenses (totally denying the embarrassing items even to himself) Recognition of defense mechanisms Observable behavior Unconscious impulse or intent Process linking the behavior and the intent Handling of defense mechanisms Bypassing Reassurance Distraction Confrontation Interpretation

 Cornerstone in the evaluation of any patients with a medical, neurological, or psychiatric disorder that affects thought, emotion, or behavior Used to detect changes or abnormalities in a persons intellectual functioning, thought content, judgment, mood, and affect and can be used to identify possible lesions in the brain

 Represents a cross section of the patients psychological life and the sum total of the nurses observations and impressions at the moment Involves observing the patients behavior and describing it in an objective, nonjudgmental manner Basis for future comparison to facilitate tracking of the patients progress over time IT IS AN EVALUATION OF THE PATIENTS CURRENT STATE

 Nurse listens closely to what is said and reflects on what is not said Patient is critically observed Global and judgmental statements are not acceptable Nurse must monitor own feelings and reactions Nurse should try to blend specific questions into the general flow of the interview

General Description - Appearance - Speech - Motor Activity - Interaction during interview Emotional State - Mood - Affect Experiences - Perceptions Thinking - Thought content - Thought process Sensorium and Cognition - Level of consciousness - Memory - Level of concentration and calculation - Information and intelligence - Judment - Insight

 Apparent age Manner of dress Cleanliness Posture Gait Facial expressions Eye contact Pupil dilation or constriction General state of health and nutrition

 Rate: rapid or slow Volume: loud or soft Amount: Paucity, muteness, pressured speech Characteristics: stuttering, slurring of words, or unusual accents

 often caused by specific brain activities (e.g. mumbling in Huntingtons chorea, slurring of speech in intoxicated patients Manic often show pressured speech People suffering from depression often are reluctant to speak at all

 Level of activity: Lethargic, tensed, restless or agitated Type of activity: tics, grimaces or tremors Unusual gestures or mannerisms: compulsions Clinical implications: - Excessive body movement may be associated with anxiety, mania or stimulant abuse - Little body activity may suggest depression, organicity, catatonic schizophrenia, or drug-induced stupor - Tics and grimaces may suggest medication side effects - Repeated motor movements or compulsions may indicate OCD - Repeated picking of lint or dirt off clothing is sometimes associated with delirium or toxic conditions

 Describes how the patient relates to the nurse Relies heavily on nurses emotional subjectivity Hostile, uncooperative, irritable, guarded, apathetic, defensive, suspicious, seductive
Suspiciousness may be evident in patients with paranoia

Irritability may suggest an anxiety disorder

 self-report of the prevailing emotional state and reflects the patients life situation Can be evaluated by asking simple, nonleading question Asking to rate his or her mood on a scale of 0 to 10 Most people with depression describe feeling hopeless Elation is common in those with mania

 Apparent emotional tone Can be described in terms of RANGE, DURATION, INTENSITY and APPROPRIATENESS Flat affect the absence of emotional expression (seen in schizophrenics) Lability shifting from one affect to another quickly (seen in manics) Incongruent affect emotional response not congruent with speech content

Hallucinations false sensory impressions or experiences - Auditory (shizophrenia) - Visual (organicity) - Tactile (organic mental disorders, cocaine abuse, delirium tremors) - Gustatory - Olfactory - Command tell the patient to do something Illusion false perception or false response to stimulus

 The specific meaning expressed in the patients communication Refers to the what of the patients thinking

how of the patients self-expression Observed through speech Patterns or forms of verbalization rather than the content

Delusion: False belief that is firmly maintained even though it is not shared by others or is contradicted by social reality Religious belief that one is favored by a higher being or is an instrument of that being Somatic belief that ones body or part of ones body are diseased or distorted Grandiose belief that one possesses greatness or special powers Paranoid excessive or irrational suspicion

Thought broadcasting belief that ones thoughts are being aired to the outside world Thought insertion belief that thoughts are being placed into ones mind by outside people or influences Depersonalization feeling of having lost selfidentity and that things around the person are different, strange and unreal Hypochondriasis somatic overconcern with and morbid attention to details of body functioning

Ideas of reference incorrect interpretation of causal incidents and external events as having direct personal references Magical thinking belief that thinking equates with doing, characterized by lack of realistic relationship between cause and effect Nihilistic ideas thoughts of nonexistence and hopelessness Obsession idea, emotion, or impulse that repetitively and insistently forces itself into consciousness, although it is unwelcome Phobia morbid fear associated with extreme anxiety

Circumstantial thought and speech associated with excessive and unnecessary detail that is usually relevant to a question, and an answer is eventually provided Flight of ideas overproductive speech characterized by rapid shifting from one topic to another and fragmenting ideas Loose associations lack of a logical relationship between thoughts and ideas that renders speech and thought inexact, vague, diffuse, and unfocused

Neologisms new word or words created by the patient, often blend of other words Perseveration involuntary, excessive continuation or repetition of a single response, idea, or activity; may apply to speech or movement, but most often verbal Tangential similar to circumstantial but the person never answers the original question Thought blocking sudden halt in the train of thought or in the middle of a sentence Word salad series of words that seem totally unrelated

Terms: - Confused - Sedated - Stuporous

Orientation: Person What is your name? Place Where are you today Time What date is today?
If patient answers correctly, note orientation x3

- The ability to recall past experiences Remote Memory: recall of events, information, and people from the distant past Recent Memory: recall of events, information, and people from the past week or so

Immediate Memory: Recall of information or data to which a person was just exposed

Confabulation making up stories to recount situations or events that cannot be remembered Techniques: 1. Repeating a series of numbers either forward or backward within a 10-second interval 2. Remembering 3 words (object, color, address) and then repeated 15 mins later

Concentration ability to pay attention Calculation the ability to do simple math How to assess calculation? 1. Count from 1 to 20 rapidly 2. Do simple calculations, such as 2x3 or 21-7 3. Serially subtract 7 from 100

7 different types of intelligence 1. Linguistic 2. Logical-mathematical 3. Spatial 4. Musical 5. Bodily-kinesthetic 6. Interpersonal 7. Intrapersonal

Assess: 1. Last grade of schooling completed 2. General knowledge 3. Use of vocabulary

Series of proverbs to assess ability to conceptualize and abstraction Examples: - When it rains, it pours. - A rolling stone gathers no moss. - People who live in glass houses shouldnt throw stones.

If the patients educational attainment is below eight grade, ask the patient to list similarities between a series of paired objects. - Bicycle and bus - Apple and pear - Television and newspaper To assess general knowledge, ask the nurse to name: - The last five presidents - The mayor - Five large cities - Occupation of a well-known person

- Involves making decisions that are constructive and adaptive - Involves ability to understand facts and draw conclusions from relationships

Hypothetical situations for the patient to evaluate:

- What would you do if you found a stamped, addressed envelope lying on the ground? - How would you find your way out of a forest in the daytime? - What would you do if you entered your house and smelled gas? - If you won $10, 000, what would you do with it?

- The patients understanding of the nature of the problem or illness

- Used when a complete full mental status examination is not practical - A simplified scored form of the cognitive MSE - Consist of 11 questions - Requires only 5-10 minutes to administer - Concentrates on only the cognitive aspects of mental function - Excludes questions concerning mood, abnormal psychological experiences, and the content or process of thinking

2 types: 1. Those designed to evaluate intellectual and cognitive abilities a. Wechsler Adult Intelligence Test (WAIS) b. Wechsler Intelligence Scale for Children (WISC) 2. Those designed to describe personality functioning (includes reality testing ability, impulse control, major defenses, interpersonal conflicts, and selfconcept) a. Rorschach Test b. Thematic Apperception Test (TAT) c. Bender Gestalt Test d. Minnesota Multiphasic Personality Inventory (MMPI)

1. 2. 3. 4.

Measure the extent of the patients problems. Make an accurate diagnosis. Track patient progress over time. Document the efficacy of the treatment.

- Used to complement nursing care and provide measurable indicators of treatment outcome