University:
West Coast University
Course:
NURS 222 | Mental Health/Psychiatric Nursing: Promoting Wellness in the Mentally Ill C
Academic year:

2023
Views:

348

Pages:

5
Author:

ilikemyicons0y5

MENTAL HEALTH ASSESSMENT Overcome language barrier Age considerations GATHERING DATA Systems review Labs & toxicology MSE Psychosocial assessment Psychosocial assessment Chief complaint Hx hospitalization, violence, self-harm, suicidal ideation FHx psychiatric disorders Medications Support system Education Occupation Sexual patterns Cognition Substance use Coping Spiritual/cultural/religious practices Underlying medical conditions Depression Stroke MS Hypothyroidism Sleep apnea Thiamine deficiency Anxiety Stimulants Angina/MI Psychosis Marijuana Migraines Alcohol withdrawal MENTAL STATUS EXAM ABC STAMP LICKER APPEARANCE Age + apparent age Race Gender Weight + height PERRLA Hygiene + grooming Facial expression Tattoos, jewellery, scars BEHAVIOUR Motor activity (akathisia, tics, hyperactivity, agitation, tremors, tardive dyskinesia) Positive symptoms Negative symptoms Posture Gait Eye contact Rapport COOPERATION Yes/no Eye contact, attitude, attentiveness SPEECH Rate Volume Tonality (monotone, tremulous) Articulation (slurring, stuttering, mumbling) Organization (disorganized, tongue-tied) Quantity THOUGHT Stream Speech poverty, pressured, slow/fast, hesitant Content Delusions, grandeur, jealousy, withdrawal/insertion, obsessions, preoccupations, nihilism, guilt, worthlessness Process Disorganized, coherent, neologisms, thought blocking, circumstantiality, flight of ideas AFFECT (OBSERVED) Range (restricted, blunted, flat, expansive) Appropriateness Euphoric/manic/hostile/irritable/sad Stability (stable/labile) Congruence MOOD (INQUIRED) Tone (sad, euphoric, duration, degree, stability) Degree (1-10 scale, extreme, moderate, mild) Irritability Stability/duration (rapid, delayed) PERCEPTION Hallucinations Sensory characteristics Content of auditory hallucinations (conspiratory, commanding) Level of discernment of reality (distinguishable/undistinguishable from reality) Level of associated distress (amused, distracted, fearful) Illusions Misperception of a real stimulus e.g. perception of insects from pattern on wallpaper Dissociations Derealization, depersonalization, detachment from self LOCS GCS Vigilance, alertness, drowsy, lethargic, confused, fluctuating INSIGHT + JUDGEMENT Insight Good/partial/poor Understanding of pathology e.g. hallucinations, suicidal ideation, treatment Understanding of medications Judgement Good/fair/impaired Problem-solving questions e.g. Òwhat would you do if you saw smoke coming out of a house?Ó COGNITIVE FUNCTION A+Ox3 LOCs Memory (short-term, recent & remote information/events) Intelligence Language (naming objects, following instructions) Abstraction (capable of describing similarities between objects, meanings of proverbs) Attention & concentration (counting, digit span tests) Visual/spatial processing (copying diagrams, drawing clock hands) KNOWLEDGE Knowledge of recent events/people/doctor ENDINGS Target (self, other person) Financial/sexual indiscretions AWOL Substance use Frequency (fleeting, constant, preoccupying) Intent (general thoughts/intentional plan) Plan Determine risk level Specificity (vague, general, detailed) Lethality (violent/non-violent) Means (weapon/vehicle possession, stockpiling medication) Immediacy (how soon?) Opportunity Determine level of risk for SI/HI Communicate risk Implement strategies to reduce risk