kneisl ch11 lecture student - napa valley college · 2015-01-22 · carol ren kneisl • eileen...
TRANSCRIPT
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Contemporary Psychiatric-MentalHealth Nursing
Third Edition
CHAPTER
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Psychiatric-Mental Health Assessment
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Comprehensive Assessment
• Enables nurse to: –Make sound clinical judgments–Plan appropriate interventions
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Psychiatric History*
• Current condition • Previous diagnosis • Previous interventions and treatments• Family history
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Categories of Data*
• Complaint/reason for admission• Present symptoms• Previous hospitalizations and
treatments• Personal history• Personality
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Collecting the Data
• The interview:–Gather information.–Establish rapport.–Structure the interview.–Keep the pace comfortable.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Interviewing Basics
• Do not rush the client in gathering the data.
• Respect the client’s need for minimal distractions.
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Mental Status Examination
• Purpose:– Gather objective data.– Deal immediately with any risk of
violence or harm.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
MSE Categories*
• General behavior, appearance, attitude*
• Characteristics of speech* • Emotional state*• Content of thought*• Orientation*
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
MSE Categories (cont'd)
• Memory*• General intellectual level*• Abstract thinking*• Insight evaluation*• Summary*
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
General Behavior, Appearance, Attitude *
• Physical characteristics• Apparent age• Manner of dress• Use of cosmetics• Personal hygiene• Responses to the examiner
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
General Behavior, Appearance, Attitude (cont'd)*• Also included:
–Posture–Gait –Gestures – Facial expression –Mannerisms–Client’s general activity level
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Characteristics of Speech*
• Loudness• Flow• Speed • Quantity • Level of coherence• Logic
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Emotional State*
• Evaluate pervasive or dominant mood or affective reaction.
• Identify objective and subjective data.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Emotional State (cont'd)*
• Pay attention to:–Constancy.–Change.
• Use descriptive terms.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Content of Thought*
• Special preoccupations and experiences–Delusions, illusions, hallucinations–Depersonalizations, obsessions,
compulsions–Phobias, fantasies, daydreams
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Orientation*
• Time• Place• Person• Self or purpose
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Memory*
• Attention span • Ability to retain or recall past
experiences• Includes both recent and remote past
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
General Intellectual Level*
• Nonstandardized evaluation of intelligence
• General grasp of information• Ability to calculate• Reasoning• Judgment
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Abstract Thinking*
• Ability to:–Make distinctions between abstractions.– Interpret simple fables or proverbs.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Insight Evaluation*
• Recognizing the significance of the present situation
• Feeling the need for treatment• Explaining the symptoms• Making suggestions for treatment
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Summary*
• Conclude the examination with important psychopathologic findings and a tentative diagnosis.
• Pertinent facts from the medical history and/or physical examination should be added.
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #1
A client presents to the mental health unit and asks to speak to the nurse. When the nurse first interacts with the client, the nurse will begin:
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #1
1.implementing nursing interventions.2.planning to care for the client. 3.the assessment process.4.evaluating the clients problems.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #2
The nurse is collecting information about the clients, previous diagnosis, interventions, and treatment. This information will be documented in the:
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #2
1.psychiatric history2.nursing plan of care3.physical assessment4.physician’s record
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #3
When assessing a client’s psychiatric history, the nurse obtains information about the client’s:
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #3
1.attitude.2.appearance.3.general behavior. 4.present symptoms.
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Mental Status Examination*
• Data to determine etiology, diagnosis, prognosis, safety issues
• More comprehensive than Mini-Mental State Exam
• Identify the personal present mental status.
• Sequence in obtaining the data can vary.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Mini-Mental State Exam*
• Questions must be asked in the order they are listed.*
• Cover the scope of a client’s thinking and reactions.
• Total score indicates the likelihood and level of cognitive decline.
• The maximum score is 30 points.*
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Mini-Mental State Exam (cont'd)
• It is used if there is not enough time to complete a full MSE.
• Main focus of the exam is cognitive functioning, but mood can be assessed.*
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Mini-Mental State Exam (cont'd)
• Client must be able to see and write. • If client is unable to perform an
activity, use Mental Status Examination.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #4
When conducting a Mental Status Examination, the nurse gathers data related to the client’s:
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #4
1.emotional state.2.previous hospitalizations.3.personality.4.present symptoms.
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #5
A client states “I cannot die, I am invincible.” The nurse documents the client’s thought content as being consistent with:
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #5
1.flat affect. 2.nihilistic delusions.3.delusions of self-deprecation.4.flight of ideas.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #6
The nurse is conducting a Mini-Mental State Examination on a client who reports “just not being able to think clearly” and an increasing awareness of “can’t seem to remember from one minute to the next.” In order to ensure validity of the examination the nurse will:
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #6
1.have the client also complete the Rorschach Test.
2.ask the client’s significant other to verify the responses.
3.have the client write out the responses at the same time the nurse records the client’s verbal responses.
4.ask the questions in the order they are listed on the tool.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Biologic and Neurologic Assessment*
• Objectives–Detection of underlying/unsuspected
organic disease –Understanding of disease as a factor in
the overall psychiatric disability–Appreciation of somatic symptoms that
reflect psychological rather than physiologic problems
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Biologic History
• Facts about known physical diseases and dysfunction
• Information about specific physical complaints
• General health history –Occupational assessment–Potential exposure to toxic substances–Medications the client is taking
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Observations*
• Gait • Hygiene and dress • Motor/neurological • Weight • Observe skin color
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Neurologic Assessment
• It is mandatory for each client suspected of having brain dysfunction.
• Goal is to discover signs pointing to cerebral dysfunction or cerebral disease.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Psychological Testing: Personality*
• Objective personality tests– Minnesota Multiphasic Personality
Inventory-2, State-Trait Anxiety Inventory, Millon Clinical Multiaxial Inventory-II, and Beck Depression Inventory
• Projective personality tests–Rorschach Test, Thematic Apperception
Test, Sentence Completion Test
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #7
The nurse-therapist would refer an incarcerated client with a long history of antisocial behaviors to the psychologist for which of the following objective personality tests?
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #7
1.Raven’s Progressive Matrices Test2.State–Trait Anxiety Inventory 3.Minnesota Multiphasic Personality
Inventory-24.Sentence Completion Test
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Psychological Testing: Cognitive Function*
• Wechsler Adult Intelligence Scale-IV• Raven’s Progressive Matrices Test • Benton Visual Retention Test
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
DSM-IV-TR Multiaxial System*
• It is evaluated on five axes, each dealing with a different class of information about the client.
• Multiaxial assessment is congruent with holistic views of people.
• It recognizes the role of environmental stress in influencing behavior.
• Data addresses adaptive strengths as well as symptoms or problems.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
DSM-IV-TR Multiaxial System*
• Axis I: Clinical disorders • Axis II: Personality
disorders/intellectual disabilities• Axis III: Present medical conditions• Axis IV: Psychosocial/environmental
factors affecting client• Axis V: Global Assessment of
Functioning
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Axis I: Clinical Disorders*
• Includes all Adult and Child Clinical Disorders*
• Includes psychological factors that would affect a physical condition:–Medication-induced movement
disorders, relational problems, and others
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Axis I: Clinical Disorders (cont'd)
• Includes conditions which may be a focus but may not constitute a clinical syndrome: –Marital problems–Occupational problems–Parent-child problems
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Axis II: Personality Disorders*
• Contains:–Personality disorders diagnosed in
adults– Intellectual disabilities diagnosed in
children and adolescents• It is also used to report maladaptive
personality traits.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Axis III: General Medical Conditions *
• Physical disorders and medical conditions that must be taken into account in planning treatment
• They are relevant to understanding the etiology or worsening of the mental disorder.
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Axis IV: Psychosocial/Environmental Factors Affecting Client *
• Problems with primary support group• Problems related to the social
environment• Educational problems • Occupational problems
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Axis IV: Psychosocial/Environmental Factors Affecting Client (cont'd)*
• Housing problems • Economic problems • Problems with access to health care
services• Problems related to interaction with the
legal system/crime
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Axis V: Global Assessment of Functioning
• Information is used to plan treatment. –Develop nursing diagnosis.
• Predict outcomes–Set goals for client behavior.
• Measure impact of treatment–Evaluate client response to
goal/treatment.• [Refer to Appendix A: Global
Assessment of Functioning]*
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #8
Using the DSM-IV-TR multiaxial system, the diagnosis of Bipolar Disorder Type II would be classified as an:
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Question #8
1.Axis I diagnosis2.Axis II diagnosis3.Axis III diagnosis4.Axis IV diagnosis
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Psychosocial Assessment*
• Dynamic process begun during initial contact
• Includes identifying characteristics such as name, gender, age, marital status, ethnic and cultural origins
• Individual, family, or group assessments
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Purposes of Assessment*
• Identify problems.• Identify client motivations, strengths,
resources.• Identify internal and external forces
that may hinder the therapeutic plan.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Purposes of Assessment (cont'd)*
• Set reasonable goals with the client.• Determine appropriate intervention
strategies. • Provide continuous evaluation and
indicate when therapeutic plan should be changed.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Resources
• APNA–The American Psychiatric Nurses
Association is the specialty organization for nurses engaged in various levels of psychiatric nursing. This site includes standards and competencies for practice.
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• Priory Medical Journals–This Priory Medical Journals site
provides a glossary of terminology used in psychiatry.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• WebMD Mental Health Assessment–This WebMD site explains the process
and purposes of mental health assessment in easy-to-understand terms.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• Citizen’s Guide to Preventing and Reporting Elder Abuse–Addresses areas of elder abuse,
explains who to report elder abuse to, and provides websites for additional information.
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Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• Mental Health America–The site provides information about
local services, support groups, and access to mental health care.
Contemporary Psychiatric-Mental Health Nursing, Third EditionCarol Ren Kneisl • Eileen Trigoboff
Resources (cont'd)
• DANA Foundation–The Dana Foundation is a private
philanthropy which serves as a gateway to general information about the brain and current brain research.