Transcript purpose of mental health psychiatric assessment.

Mental Health Assessment
Ms. Rica A. Santos, RN
Objectives







Describe the purpose and principles associated with the clinical
interview.
In the roles of teacher, caregiver and communicator, assess the
client holistically using the balancing factors in crisis as a
baseline.
Differentiate client levels of insight.
Describe the purpose of mental health psychiatric assessment.
Perform the Mini Mental Status Examination.
Compare and contrast the DSM-IV classification system to
nursing’s NANDA system.
Differentiate between nurse-administered mental health
appraisals and projective psychological testing.
Mental
Health
vs.
Mental
Illness
Mental health vs. mental illness


Depends on what a particular culture
regards as acceptable or unacceptable.
Myths and misconception

Different and Odd
Mental Illness


Mental ill are those who violate social
norms and thus threaten (or make
anxious) those observing them.
Psychopathology
Mental Health


Successful performance of mental functions, resulting
in the ability to engage in productive activities, enjoy
fulfilling relationships and change or cope with
adversity.
Provides people with the capacity for rational
thinking, communication skills, learning and
emotional growth, resilience and self-esteem
(US Department of Health and Human Services, 1999)
Mental Health

Changes over time and reflects changes
in cultural norms, society’s expectations
and values, professional biases,
individual differences, and political
climate of the time
Attributes of Mental Health









Think clearly
Ability to control one’s behavior
Ability to take responsibility for one’s actions
Ability to live without (undue) fear, guilt, or anxiety
Capacity to deal with conflicting emotions
Ability to love and experience joy
Accurate appraisal of reality
Ability to play and laugh
Maintain a health self-concept and self-value
Attributes of Mental Health




Ability to work and be productive
Negotiate each developmental task
Attain self defined spirituality
Relate to others
Mental Health vs.
Mental Illness
Signs of mental health
Signs of mental illness
Happiness
Major Depressive Episode
Control over behavior
Control disorder, undersocialized, aggressive
Appraisal of reality
Schizophrenic disorder
Effectiveness in work
Adjustment disorder in work (or Academic)
Inhibition
A Health Self Concept
Dependent Personality Disorder
Satisfying relationship
Borderline personality disorder
Effective coping strategies
Substance Dependencies
Continuum
Ill
Healthy
Influences that
can affect mental health





Inherited factors
Biological influences
Hormonal influences
Health practices and beliefs
Cultural/subcultural beliefs and values
Influences that
can affect mental health








Negative influences (psychosocial stressors, poverty,
impaired/inadequate parenting)
Demographic and geographic locations
Personality traits and states
Developmental events
Family influences
Spirituality, religious influences
Available support system
Environmental experiences
The Nursing Process in
Psychiatric Mental Health Nursing
Assessment
•Construct Data Base
•Verify the Data
Nursing Diagnosis
•Identify Problem and
etiology
•Construct nursing
Diagnoses
•Prioritize
Evaluation
Outcome Identification
Implementation
Planning
•Identifying interventions
Assessment
Mental Health/
Psychiatric History






identifying information
presenting problem
history of present illness
family history
personal history
current social status
Mental Status Examination








Personal Information
Appearance
Behavior
Speech
Affect and Mood
Thought
Perceptual Disturbances
Cognition
Personal Information








Age
Sex
Marital status
Religious preference
Race
Ethnic background
Employment
Living arrangements
Appearance










Grooming and dress
Level of hygiene
Pupil dilation or constriction
Facial expression
Height, weight, nutritional status
Presence of body or tattoos, scars, other
Relationship between appearance and age
Posture
Motor activity
Voice
Behavior





Excessive or reduced
body movements
Peculiar body movements
Abnormal movements
Level of eye contact









Cooperative
Withdrawn
Apathetic
Suspicious
Aggressive
Compliant
Histrionic
Anxious
Relaxed
Hostile
Speech




Rate: slow, rapid, normal
Volume: loud, soft, normal
Disturbances
Cluttering
Affect and Mood


Anxiety
Suicidal/homicidal
ideas
 “Beck Depression
Inventory”






Appropriate
Flat
Labile
Sad
Elated
Angry
Thought Process








Logical
Circumstantial
Dissociated
Obsessive
Phobic
Suicidal
Flight of ideas
Ideas of reference
Perception



Illusion
Delusions
Hallucination
Cognition








Orientation: time, place, person
Level of conscious
Memory
Fund of knowledge
Attention
Abstraction
Insight
Judgement


Open word file
Mini mental state examination
HEADSSS
Psychosocial Interview Technique







Home environment
Education and employment
Activities
Drug, alcohol or tobacco use
Sexuality
Suicide risk or symptoms of depression
Savagery


Spiritual assessment
Cultural and Social Assessment
Psychological Testing

Intellectual functioning (IQ test)

“WAIS” Wechsler Intelligence Scale
Find two words, one from each group, that are closest in meaning.
Group A
raise
floor
stairs
A. raise and elevate
B. raise and top
C. floor and basement
D. stairs and top
E. floor and elevate
Group B
top
elevate
basement
What is the missing letter?
E
B
G
D
C
A
B
B
O
B
N
?

Personality tests


Objective – count the score against a standard
Projective
 Rorshack (“inkblot” test)
 Thematic Apperception Test (TAT)
 Draw a person test – reflects body
image
 Minnesota Multiphasic Personality
Inventory

The MMPI has 10 clinical scales that are used to indicate different psychotic conditions.
Despite the names given to each scale, they are not a pure measure since many
conditions have overlapping symptoms. Because of this, most psychologists simply refer
to each scale by number.
Scale
Scale
Scale
Scale
Scale
Scale
Scale
Scale
Scale
Scale
1
2
3
4
5
6
7
8
9
0
– Hypochondriasis
– Depression
– Hysteria
- Psychopathic Deviate
– Masculinity/Femininity
– Paranoia
– Psychasthenia
– Schizophrenia
– Hypomania:
– Social Introversion
Examples




Depression - “I often feel that life is not worth living”
Paranoia - “Several people are following me
everywhere”
Schizophrenia - “I seem to hear things that other
people cannot hear”
Psychopathic deviance - “I often was in trouble in
school although I did not understand for what
reasons.

Appraisals that can be Nurse Administered



Tests for depression
 Beck depression inventory
 Geriatric depression scale
 Spices
 Self-rate scale 1-10
 Happy face
Suicide/self-harm assessment
Mini-mental status exam

Assessing Using Mental Health Assessment Tests







Concentration (attention span)
Memory; recent/remote
Intelligence
Abstract thinking
Insight and judgment
Mini-Mental Status Exam
Brief Psychiatric Rating – thoughts and perceptions

Psychosocial Assessment




Social history
Interpersonal relationships
Sexual history
Alcohol and substance dependency (abuse)
Medical and Nursing
Diagnosis of Mental Illness
Diagnostic and statistical manual of
mental disorders (DSM-IV-TR)


Manual that classifies mental disorders
Focuses on research and clinical
observation when constructing
diagnostic categories for a discrete
mental disorder
Medical Diagnosis
and DSM-IV-TR



A common misconception is that a
classification of mental disorders
classifies people when actually the
DSM-IV-TR classifies disorders that
people have
Schizophrenic
Alcoholic
DSM-IV, Axis I-V





Axis I – Clinical syndromes
Axis II – Development disorders and personality
disorders pervasive since childhood
Axis III – Physical and medical disorders/conditions
Axis IV – Severity of psychosocial stressors: Coded
from 1 (none) to 6 catastrophic (death of child)
Axis V – Global assessment of functioning: Coded
from 100 (absent or minimal anxiety) to 10 or lower
(persistent danger of suicide)
DSM-IV-TR Multiaxial system
Axis
Axis I
Clinical Disorders
Other conditions that may be a
focus of clinical attentions
Axis II
Personality disorder
Mental retardation
Axis III
General medical conditions
Axis IV
Psychosocial and environmental problems
Axis V
Global Assessment Functioning
Example
Major depressive disorder
Dependent personality disorder
Diabetes
Divorce 3 months previously
31 years old and unable to work
or respond to family and friends
Nursing Diagnosis
and DSM-IV-TR


Diagnosis and treatment of human responses to
actual or potential mental health problems
NANDA
 Impaired adjustment
 Anxiety
 Disturbed body image
 Caregiver role strain
 Acute Confusion
 Interrupted family processes
 Ineffective individual coping
 Spiritual distress
DSM-IV-TR

In culturally diverse populations

Social bias

Homosexuality is included in the first and
second editions of DSM
Over the past 4 months, George has struck and injured several dozen
people, most of whom he hardly knew. Two of them has been sent the
hospital. George expresses no guilt, no regrets. He says he would attack
every one of them again of he got the chance.
What should we do to George?
A. Send him to jail
B. Commit him to a mental hospital
C. Give him an award for being the best defensive lineman in
the league
Aunt Tillie starts to pass out 5 dollar bills to strangers on the
street corner and vows that she will keep on doing so until she
has exhausted her entire fortune. Is she mentally ill?
Caution must be exercised to avoid labeling
or streotyping when a medical diagnosis or
a nursing diagnosis is being formulated.
That every society has its own view of
health and illness and its own
classification of disease has long been
observed by anthropologists, historians,
and students of cross-cultural society
(Klerman, 1986)
Balancing Factors in Crisis

Perception of self and event.
 “How are you in the midst of all that’s
going on in your life right now?”
 “What are your ideas about what is
happening - - the causes or what the
deeper crisis is?”
 “In what ways are you having trouble
believing you’re going to be okay?”
Balancing Factors in Crisis


Situational support.

“Who can you turn to?”

“Who cares about you?”
Coping mechanisms.

“What do you usually do to help yourself
feel better?”

“What are your ideas about why this isn’t
working now?”
Case
Last night the patient was caught shop lifting and was
charged with a crime, and now he has a court date
pending. He was released to his family. Shortly after his
return home he ingested the tablets. He did not tell
anyone until he was discovered to be vomiting profusely
and taken to the emergency room by his mother. He told
the physician that when he took them he wanted to die.
His mood and affect are depressed and blunted.
J.S. is a 19 year old college freshman, who was referred from
the emergency room following an overdose of
approximately 40 acetaminophen extra strength. He was
cleared medically. He had been in outpatient counseling
once a week since an initial overdose six months ago.
He states his appetite and sleep have been poor and he
believes he has lost 10 pounds over the last month.
He is anhedonic and his grades are dropping due to
inability to concentrate. He is unable to describe any
reason for this. He has thought of suicide in spite of
intervention. There is no evidence of psychosis or a
thought disorder.
Nursing Diagnoses



Risk for violence: self-directed
Ineffective individual coping
Altered nutrition: less than body
requirements