Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing                                          UNIT- 1 PSY...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing         treatment modalities planned, frequency of v...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing 8.    Be reassuring and supportive                  ...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing                                      UNIT-2 PSYCHIAT...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingproblems, interpersonal problems, socioeconomic probl...
Booklet on Psychiatric Nursing Skills toTeachers of School of NursingDetails of family functioning                        ...
Booklet on Psychiatric Nursing Skills toTeachers of School of NursingAge of beginning               :Age of finishing     ...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing7. PREMORBID PERSONALITY:                            ...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing                             UNIT-3 SYMPTOMATOLOGY IN...
Booklet on Psychiatric Nursing Skills toTeachers of School of NursingIllusions                                            ...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing          the remarks or actions of people he meets a...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing2.    Distractibility                                ...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing                                      UNIT-4 MENTAL S...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingthey are controlling or yielding. Phobias may also be...
Booklet on Psychiatric Nursing Skills toTeachers of School of NursingThe examiner after instructing the clients, gives an ...
Booklet on Psychiatric Nursing Skills toTeachers of School of NursingB. MINI MENTAL STATUS EXAMINATION (MMSE)             ...
Booklet on Psychiatric Nursing Skills toTeachers of School of NursingIII Eyes:                                            ...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing                            UNIT - 5 PHYSICAL  NEUROL...
Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingneurological assessment. The exam ination requires sk...
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First Aid

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By Bivin Jose. II MSc in Psychiatric Nursing National Institute of Mental Health and Neurosciences, Bangalore

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  1. 1. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT- 1 PSYCHIATRIC INTERVIEW Dr. R. Parthasarathy Ms.Shobitha Dr.Nagarajaiah Professor Ph.D Scholar & Psy.Social Worker Associate professor Dept. of psychiatric social work Dept. of Nursing NIMHANS, Bangalore-29 NIMHANS, Bangalore-29Interviewing requires linguistically and culturally effective 7. Medical history: All medical disorders past and presentcommunication skills, interviewing, behavioral observation, and their treatments and childhood disorders thatdata base record review and compressive assessment of the involve the central nervous system. For females,client and relevant systems enables the psychiatric mental pregnancy status - especially if on psycho tropics ornurse to make sound clinical judgments and plan appropriate expecting the use of psycho tropics and precautionsinterventions with the client. against pregnancy and concomitant pharmacological treatment can all patients, but particularity in consult-Interviewing is a specific type of guided and limited liason work, the medical history includes theintercommunication with an identified purpose. An interview interrelation of medical and psychiatric conditions.is usually conducted to collect a database for analysis anddecision making purpose. 8. Social history, pre-morbid personality - early developmental history: Early developmental history,The goal of the initial diagnostic interview is to collect specific, description of pre-morbid personality as baseline fordetailed information about 15 topics. These topics constitute patients best level of functioning. The patientsthe psychiatric evaluation. psychosocial and environmental conditions 1. Identifying data: Patients name, sex, age, marital status, predisposing to precipitating, perpetuating and address, occupation, income, etc protecting against psychiatric disorders. Pre morbid 2. Chief complaints: The chief complaint in the patients versus morbid functioning. Present support system. own words. Alternatively signs of disordered functioning 9. Family history: Psychiatric history of first-degree observed by the interviewer. relatives, including treatment response as possible 3. Informants: A list of all informants, their reliability, and genetic predisposition for the patient. level of cooperation; also previous hospital records, if 10. Mental status examination: Appearance, available. Such informants are essential in consciousness, psychomotor functions, speech, circumstances that prevent the patient from providing thinking, affect, mood, suggestibility and thought adequate information. Choosing the right set of content; cognitive functions such as orientation, informants is more important than having a great memory, intelligence and executive functions; insight number of informants. and judgement. 4. Reason for admission/consultation: the referral source; 11. Diagnostic formulation: Summary of biological, in case of hospitalisation, statement of legal status - psychological and social factors contributing to patients voluntary - and the reason why hospitalisation is the psychiatric disorders. safest and least restrictive environment for treatment. 12. Differential diagnosis: Discussion of diagnostic options 5. History of present illness: Early manifestations and based on overlapping symptomatology recent exacerbations of all psychiatric disorders 13. Multiaxial classification: Information on all five axes present; review of diagnosis and treatments given by other providers. 14. Assets and strengths: Inventory of patients knowledge, interests, aptitudes, education, and employment status 6. Psychiatric disorders in remission: Psychiatric to be used in the treatment plan. disorders presently in remission; especially substance abuse disorders; psychiatric disorders first diagnosed 15. Treatment plan and prognosis: Account of in childhood and adolescence and their treatments. psychopharmacological, psychological and social 1
  2. 2. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing treatment modalities planned, frequency of visits and 3. Guidelines for interviewing list of providers; discharge criteria if inpatient. 1. Build rapport with the patientFor collecting such comprehensive information the interviewer 2. Conduct sessions seated in a private, comfortable areahas to master the styles of interviewing and apply them to the with adequate lighting and hearing distancefour components of the interview: rapport, techniques, mental 3. At the beginning of each session, plan and discussstatus and diagnosing. with the client the length and purpose of the session.2. Five phases of the psychiatric interview and four 4. Observe, listen and use facilitative communicationcomponents techniquesThe psychiatric interview progresses over time, which can be 5. Convey a professional demeanour through dress andarbitrarily subdivided into five phases. These phases cover mannerthe 15 topics of the psychiatric evaluation 6. Summarize the interaction at the end of the sessionPhase I: Warm up and chief complaint (I to IV) and make arrangement with the client for the next sessionPhase II: The diagnostic decision loop (V) 7. Positively reinforce the client for his attention, effort andPhase III: History and database (VI to X) involvementPhase IV: Diagnosing and Feedback (XI to XIV) 8. Maintain unity, progression and thematic continuityPhase V: Treatment plan and Prognosis (XV) 9. Develop a good confidence so that the client is preparedThe five phases divide the psychiatric interview longitudinally. for self disclosureCross-sectionally, the interview consists of four components, 10. Maintain non-judgemental attitude and respond to selfwhich the interviewer must continuously monitor and propel disclosure with honesty, support and acceptancethroughout. 11. Limit your self-disclosure to a minimal level1. RAPPORT: focuses on the therapist - patientrelationship; a good rapport is prerequisite for an effectiveinterviewer. Rapport is established in the opening; with a 4. Interview skillscooperative and insightful patient, there is often little problem Careful listeningin establishing and maintaining a good rapport. However in Attendingpatients who are uncooperative or show poor insight, Demonstration of sincere interestestablishing a workable rapport with the patient becomes acentral issue. Expression of attentiveness through eye contact, body language, verbal back and appropriate use of silence2. TECHNIQUE: refers to the approaches the intervieweruses to keep an interview on track. It includes skills to Concreteness in questions/probingappropriately select questions to arrive at a diagnosis. Good Immediacy - immediate importancetechnique is necessary to therapeutically engage and work Experimental and didactic confrontationwith difficult patients.3. MENTAL STATUS: assessment captures the patientsexperiences, symptoms, signs behaviours, thought content, 5. Some dos and donts while conducting interviewcognitive level of functioning, insight and judgement during 1. Maintain eye to eye contactactual time of the interview; however, in a patient with a 2. Interrupt only when necessarysignificantly altered mental status - whether it be a boisterous, 3. Ask always open ended questionsirritable and uninterruptible manic patient, a minimallyresponsive depressed patient or a paranoid patient - his or 4. Dont be in a hurryher mental status plays a significant role in the interview. 5. Do not pass judgments4. DIAGNOSIS: Pursues a progression in the diagnostic 6. Do not threatendecision process from chief complaint to final diagnosis. 7. Dont belittle 2
  3. 3. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing 8. Be reassuring and supportive also assess the patients non verbal cues in order to get an 9. Clarify accurate picture of the patients mental status. 10. Give time Reference: 11. Prepare 1. Booklet on clinical skills in psychiatric nursing. 12. Record the information after the interview is over Department of nursing. National Institute of Mental Health and Neuro Sciences Bangalore-560 029.india/Getting maximum information, in a short time as possible, 2009.without causing any distress to the client is "good interviewing"and it is an art. By practice one can master it. 2. Kathy Neeb. Fundamentals of mental health nursing. 3rd ed. Jaypee. New Delhi. 2008 3. Sreevani R. a guide to mental health and psychiatricConclusion: nursing. 3rd ed. Jaypee. New Delhi.2010.Interview is a method by which the nurse starts establishing a 4. Vracarolis EM, Halter MJ. Foundations of psychiatrictherapeutic relationship with the patient. The nurses need to mental health nursing- A clinical approach. 6th ed.use her verbal and non verbal communication techniques and Saunders. St. Louis . 2010. 3
  4. 4. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-2 PSYCHIATRIC HISTORY-TAKING Dr.Nagarajaiah Associate professor Dept. of Nursing NIMHANS, Bangalore-29A comprehensive, accurate and adequate history from the 11. Income (annual) : Self - Family -patient and reliable informant will help in understanding the 12. Religion : Hindu / Muslim /Christian / othersproblems of the patient and also in planning the appropriatemanagement. With regards to psychiatric patients it is very 13. Reasons for consultation/admission:important to obtain information from a close relative or a person 14. Source of referral and reasons for referral:who knows well about the patient. This is because psychiatricpatients are not aware of the extent of their symptoms always. Source of Information gathered from: adequate/ reliableFor example a schizophrenic patient may not realize how muchembarrassment he has caused by his disturbed behavior and 2. PRESENTING COMPLAINTS (chronological):also in case of alcoholics, they may know their problems but The duration of each presenting complaints should bemay not wish to reveal them. mentioned in chronological orderHistory should always be recorded systematically and in thesame order to ensure that the interviewer does not forgetimportant themes or events. Given below a standard scheme 3. HISTORY OF PRESENT ILLNESS:of history taking in the form of list of topics to be covered. The Durationtrainee must learn by experience how to adjust his questioning Current episode /exacerbation:to problems that emerge as the interview proceeds. This isdone by keeping in mind the decisions about diagnosis and Mode of onset : Abrupt <48 hrs Acute <1wk Insidious 1-2management that will have to be made at the end of the Sub acute few weeks - monthsinterview. Course : Continuous /Episodic /Unclear (Fluctuating /1. SOCIO DEMOGRAPHIC DATA Deteriorating /Improving)1. Name : Precipitating factors : (Describe) this can be physical (e.g febrile illness) or psychological in nature (death/loss).2. Fathers / spouse name: Description :3. Address : Chronological account, describe major abnormal behavior,4. Phone number : associated problems like homicide/ suicide/ disruptive5. Age : behavior/ thought content as expressed in speech/ writing,6. Sex : major mood states, abnormal perceptions and experiences, biological functioning, occupational functioning, effects on7. Languages known : work, social functioning, changes in daily life etc. Description Can speak Can write Can read of the time relations between symptoms and social psychological and physical disorder needs to be mentioned.Mother tongue : Associated disturbances in sleep, appetite, and sexual driveOther languages : have to be mentioned. Any treatment received, improvement and deterioration has to be noted down.8. Marital status : Scheme for substance abuse/ dependence cases:single /married /separated /divorced / widow /widower /other Mode of initiation, duration, quantity of consumption, early9. Education : pattern of intake, progression, salience, tolerance, craving,10. Occupation : physical withdrawal features, pattern of use in recent and past, medical complications (including accidents) neuropsychiatric 4
  5. 5. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingproblems, interpersonal problems, socioeconomic problems(including debts if any) occupational problems, problems withlaw, earlier attempts to abstain, reason for consultation,motivation for abstinence etc.In cases of multi substance use describe separately for eachsubstance.Treatment historyNote the details regarding treatment received. For e.g.:Magic-religious/ other systems like Homeopathy/ Ayurveda/AllopathicPsychiatric pharmacotherapy- name of the drug; duration; D Ddosage; side effects; compliance; others.ECTs- No. of ECTs. ReasonPsychotherapy DFamily interventionsRehabilitative measuresNegative history Major features that are usually present in the given syndrome History of trauma, fever, headache, vomiting, confusion, memory disturbances, Physical illnesses like, hypertension, diabetes, etc. Other major psychiatric illnesses Organic causes Substance abuse4. PAST HISTORY:Chronological account since childhood has to be noted down.If possible draw an life chart. Describe each episode brieflywith onset, events, major features, course and duration,treatment taken, level of recovery.Psychiatric illness: ^Medical illness:5. FAMILY HISTORY: Describe each family member briefly: age, death, mode ofGenogram - Family of origin death, education, occupation, health status - physical and psychological illnesses, major personality traits, relationshipDraw the tree for three generations on both sides in cases of with client, include other significant members.genetic importance 5
  6. 6. Booklet on Psychiatric Nursing Skills toTeachers of School of NursingDetails of family functioning 9. Social support system:1. Type of family : (Nuclear / Joint / Others) 10. Other :2. SES : (Upper / Middle / Lower)3. Leadership pattern: History of illness in family:4. Role functions : Psychiatric: similar illness, other illness, other major behavioural problems like delinquency, personality problems,5. Communication with in the family and others: suicide, substance use, epilepsy, mental retardation.6. Child rearing practices: Medical: (Especially hereditary)7. Interpersonal relationships:8. Social position :6. PERSONAL HISTORY:Birth and development :Antenatal period : Uneventful / Eventful (specify)Birth history : Full term /Premature / Post mature, Normal /Forceps/ Caesarean/ Delayed birth cry / any other complications.Post natal history : Uneventful / Eventful (specify)Physical health during infancy: Good / poor (specify)Immunization schedule : Completed / not completedDevelopmental milestones : Normal / DelayedMotor :Adoptive :Speech :Social :Childhood health : Normal/ Abnormal/ Trauma/ Fever/ Convulsions/ Any other illnessBehavioral and emotionalproblems : (Nail biting, thumb sucking, sleep disturbances, tics, mannerisms, Enuresis, Sleep walking, Temper tantrums, stammering. Look for conduct disturbances like frequent fights, truancy, stealing, gang activities and relationship with parents, siblings and peers)Home atmosphere duringchildhood : Satisfactory / UnsatisfactoryEmotional problems inadolescence : running away / delinquency/ smoking/ drug taking/ over weight/ identity problemsHome atmosphere duringadolescence : Satisfactory / UnsatisfactoryParental lack : Yes / No (Dead/ separated fro more than one year/ habitually absent from home)Anomalous family situation : Yes / No (Step parent, adoption status)Comments :Educational history : 6
  7. 7. Booklet on Psychiatric Nursing Skills toTeachers of School of NursingAge of beginning :Age of finishing :Relationship with teachers :Relationship with schoolmates(include nick names, bully orbutt of jokes :Position in class : (Top / Middle / Low)Special abilities :Active participation in games:Other extracurricular activities :Occupational history :Work record : Satisfactory / UnsatisfactoryFrequent changes of jobs : Yes / NoWork position : Raising / Falling / StationaryAge at the time of starting towork :Jobs held in the past (in chronological order, with wages, dates, reasons for change)Present job : Duration:Satisfied with work : Yes / No (Reasons for dissatisfaction)Sexual history:Information about sex : (How acquired, of what kind, how received, adequacy of knowledge, attitude towards opposite sex)Masturbation : Age of starting : Frequency: (Guilt/ attitude if any,)Sexual experience : (Homo/ Hetero/ Pre and extra marital / preferences)Any complaints includingDhat syndrome :Menstrual history :(Age at menarche / how regarded / regularity / duration / cycle / amount / physical / emotional problems)Menopause : (Age / climacteric symptoms)Marital history:Genogram - family of procreationDate / year of marriage (Arranged / affair)Spouse : (Age, education, occupation, personality)Marital relationship : Satisfactory / UnsatisfactorySexual relationship : Satisfactory / UnsatisfactoryContraceptive practices :Children: (Chronological list of children, miscarriage and still births (age, education, occupation, personality for each child, relationship with client) 7
  8. 8. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing7. PREMORBID PERSONALITY: Conclusion:(Give details and cite examples from patients past life) History taking is the first for managing a patient in the psychiatrici. Social relations set up. A well taken history in itself is enough to diagnose asii. Intellectual activities : Hobbies and interests well as management the patient. Therefore the art of taking history should be essentially inculcated in all psychiatriciii. Mood (cheerful, strung up, optimistic, pessimistic, stable, nurses.fluctuating etc.)iv. Character Reference:a. Attitude to work and responsibility 1. Booklet on clinical skills in psychiatric nursing.b. Interpersonal relationships Department of nursing. National Institute of Mental Health and Neuro Sciences Bangalore-560 029. India/c. Standards in moral, religious, social and health matters. 2009.d. Energy and initiative 2. Kathy Neeb. Fundamentals of mental health nursing.v. Fantasy life 3rd ed. Jaypee. New Delhi. 20088. Habits: 3. Sreevani R. a guide to mental health and psychiatric Eating fads / patterns nursing. 3rd ed. Jaypee. New Delhi.2010. Sleeping patterns 4. Vracarolis EM, Halter MJ. Foundations of psychiatric Excretory functions mental health nursing- A clinical approach. 6th ed. Alcohol consumption Saunders. St. Louis . 2010. Tobacco consumption Self-medication with drugs 8
  9. 9. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-3 SYMPTOMATOLOGY IN MENTAL DISORDERS Dr. Ramachandra Associate professor Dept of nursing, NIMHANS, Bangalore-29The systematic study of cognition and behavior is called b) Stereotype Movementpsychopathology. Symptoms are the result of many forces.Their origin is usually within the patient. The symptoms may Mannerisms: These are stereotyped movementsbe very bizarre but have a cause and meaning. Various commonly seen in Schizophrenia. Ex: grimacessymptoms observed in mental illness are addressed under repeated gestures and peculiarities of gait etc.the following headings. c) Stereotype Speech1. Disorders of motor aspects of behavior Verbigeration: Repetation of words phrase or sentence2. Disorders of perception is called verbigeration.3. Disorders of thinking 1.5 Automatic Behaviour4. Disturbances of affect In this patient follows compulsively and automatically suggestions and requests. This is seen in two forms:5. Disturbances of attention Echolalia: patient repeats the words or phrases which6. Disorders of consciousness are spoken in his presence.7. Disorders of orientation Echopraxia: patient imitates the action of others.8. Disorders of memory 1.6. Negativism It is a psychological defense reaction manifested by1. DISORDERS OF MOTOR ASPECTS OF BEHAVIOR opposition and resistance to what is suggested. This Motor disturbance are related to action or impulse toward can be exhibited in different forms such as mutism, action. It is called conation. These activities are related refusal of food and noncompliance with requests etc. to attitude and feeling. Negativism provides gratification by the acting out of hostile, revengeful feelings towards significant persons.1.1. Increased activity (over activity) Increased activity may be goal directed. But sometimes 1.7. Compulsions the goal of the activity is constantly changing so no A morbid and often an irresistible urge to perform objective is achieved. Ex: Mania. Even the stream of the purposeless act repetiously is known as compulsion. thought is characterized by flight of ideas. Ex: touching an object twice or may take form of ritual.1.2. Decreased activity 1.8. Violence Patient takes long time to start the activity when it gets started they do it very slowly. They have to make lots of Violence is an expression of aggressiveness in the form effort to do it. In extreme form, the patients are mute and of murders, assaults, rape damaging self and others motion less. Ex: severe depression. and suicide.1.3 Repetitious activities 1.9. Suicide The patient repeats the activity in the same manner for It means self-destruction. People with suicidal ideation an indefinite period. have sense of lack of love and affection and deep sense1.4 Stereotypy of personal rejection. They also suffer from self- derogatory attitude, profound feelings of hopelessness Persistent and constant repetition of certain activities and helplessness. The suicidal attempt is motivated by and may be of position, movement of body or speech. the wish for revenge or by wish-fulfilling fantasies of Stereotypy is seen in the following forms. reunion in death. a) Stereotypy position Catalepsy: A constantly maintained immobility of position is known as catalepsy. It is frequently seen in DISORDERS OF PERCEPTION Schizophrenia. Disorders of perceptions are classified as illusions and Waxy -flexibility: Here patient flex his extremities like wax hallucinations. in awkward position and remains in that position for long time. 9
  10. 10. Booklet on Psychiatric Nursing Skills toTeachers of School of NursingIllusions B. Retardation: In this initiation and thought are slow; patient will speak slowly and usually in low tone.Illusions are mistaken or misinterpretations of sense Patient will complain that he has difficulty in thinking.impressions. Ex: patient perceives rope as a snake. Illusions It usually occurs in depressive phase of affectiveoccur due to individual emotional state, needs and fears. psychoses and may be in schizophrenia.Hallucinations C. Perseveration: In this abnormal, persistent repetitionHallucination is a perception without object. Hallucinations or continuance is seen in expression of an idea. Itshould be looked upon as mental products which, arising occurs in aphasia, catatonia and in senile dementia.from within and not related to any external stimulus. They D. Circumstantiality: This is also disturbance of flow ofrepresent a breakthrough of preconscious or thought in which patient includes many unnecessaryunconsciousness in the form of sensory images in response details before the goal is finally reached. This is seento psychological situations and needs. in feeble-minded, epileptics and in advanced senileTypes of Hallucinations mental disorders.1. Auditory Hallucinations: These are most common form E. Incoherence: This is characterized by confusion due of perceptual disturbances. These are sometimes in the to repressed material highly charged affectively. In form of noises but commonly in clear words or complete this one idea runs in to another with logical sequence. sentences addressed to him. It occurs in schizophrenia.2. Visual Hallucinations: These are not common as auditory F. Tangentiality: In this disorder of progression of thought hallucinations. These occur most commonly in delirium patient begins to respond, follows a series of related tremens in which patient sees terrifying images and topics but never reaches the goal finally. It is common causes fear to the patient. in Schizophrenics.3. Olfactory Hallucinations: These are hallucination of smell, G. Blocking: When patient is talking and suddenly he commonly seen in Schizophrenic states and with lesions stops talking. It means sudden interruption in train of of the temporal lobe. They are unpleasant and represent thought. It occurs when one feels strong affect. Eg feelings of guilt. anger or terror and Schizophrenics.4. Gustatory Hallucinations: these are hallucinations of taste. 3. Disorders of content of thought They rarely occur alone but are associated with olfactory A. Overvalued or over determined ideas: When an idea hallucinations. has strongest feeling tones it tends to dominate and5. Tactile Hallucinations: these are the hallucinations of the we call it over valued idea. Overvalued idea becomes touch. They occur principally in toxic states. Ex: delirium most important determinant of behavior. This is how tremens, in cocaine addiction and in Scxhizophrenia also. delusion occurs.6. Kinesthetic Hallucinations: The phantom phenomenon. B. Delusions: The delusion is defined as common false Ex: to feel pain in the amputated part of limb. This is the beliefs, which are irrational, not shared by persons of most common form of kinesthetic hallucinatory experience. same race, age and standard of education, which is held by conviction and which cannot be altered byDISORDERS OF THINKING logical arguments and which are persistent.Thought is the most highly organized psychobiological Types of Delusionsintegration and a form of implicit or internal behavior. I. Delusions of grandeur: Delusional beliefs of great1. Disorders in the form of thought power, wealth and influence. Ex: he may say he isThinking is the product of stimulus and response. Stimuli for god. This delusion arises from feelings of insecuritythought come from various sources. In day dreaming thinking or inferiority.is directed by egocentric wishes and instinctual needs. In case II. Delusions of Self-accusation: it arises when super-of Schizophrenia, thinking is directed by unconscious factors. ego becomes critical became repression getsEx: autistic thinking or drastic thinking. weakened and patient has vague feeling of guilt. This2. Disorders of progression of thought (Stream of thought) sense of guilt takes the form of self-accusation.The following are the disorders of the thought. III. Delusions of persecution: Delusional beliefs of an individual that he is being deliberately interfered with, A. Flight of ideas: This is the disturbance of the stream discriminated against, threatened or otherwise of thought in which thinking process appear to run mistreated. He feels others are planning to harm him. too quickly yet no idea is completed is known as flight These delusions permit a shifting of responsibility of ideas. This happens because of increased inner and otherwise serve to relieve anxiety arising from drive and distractibility. Sometimes a word similar in guilt. It occurs in chronic psychotic disorders. sound but not in meaning calls up the new thought and may lead to senseless rhyme, e.g. Sit, sob, sigh, IV. Ideas of reference: Delusional beliefs that other sorrow. This is called clang- association. people are talking about him referring to him or that 10
  11. 11. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing the remarks or actions of people he meets are 3. Anxiety intended to have some special significance for him. It is a persistent feeling of dread, apprehension and In paranoid states ideas of reference represent a impending disaster. The patient is ignorant of its source. projection of the patients own self-criticism on to the Following are the different states of anxiety. world. In depression, feeling of guilt may stimulate ideas of reference. A. Free-Floating anxiety: It means anxiety is not attached to any ideational content but is felt as a morbid fear V. Delusion of guilt : Impoverishment and illness These without apparent source. occur mostly in depressive cases. In this unconscious hostile tendency may be projected B. Agitation: when anxiety is severe and over flows in outward giving rise to fear of punishment. this way in to the muscular system, producing gross motor restlessness, the reaction of the patient isC. Hypochondria: In this patient shows exaggerated concern called agitation. over physical health. In this anxiety is displaced from unconscious mental sources to organs. It occurs in people C. Tension: In this patient feel restlessness, who have shown previous tendency to evade the dissatisfaction, dread and discomfort. Tension is responsibilities of life through illness. accompanied by neuromuscular setting.D. Obsessions: Thoughts that persistently push themselves D. Panic: It is a pronounced state of anxiety which in to consciousness against the desire of the patient are produces disorganization of ego functions. It occurs known as obsessions. Obsession thoughts are strongly in some long standing insecurity of the personality charged with the emotions of guilt or depression. Ex: which creates tension in threatening form the patient patient keeps on asking why he was born. Obsession may show aggressiveness and about, pupils get thoughts are closely related to compulsive acts. dilated and has difficulty in thinking, appearance of bewilderment. Suicide may occur.E. Phobias: Allied to obsessive thoughts the patient has fears of dirt, bacteria,cancer or of crowds. 4. In adequate AffectDISTURBANCES OF AFFECT This is emotional dulling or detachment in the form of indifference, also called apathy. Patient does not feel pleasureAffect is related to feeling which currently the person is having or pain or any other sentiments. This absence of emotionalwhereas mood is sustained feeling state of considerable responsiveness may cause out of touch with reality. It mayduration. Affect serves as warning signal to refrain from a appear as a protective, defensive reaction against painfulforbidden act. Affect influence our thoughts and ideas. perceptions.1. Pleasurable affects 5. Inappropriateness of affect A. Euphoria: It is the feeling of emotional and physical wellbeing. In this patient has optimistic mental set and It is a disharmony of affect. It is common emotional is confident and assured in attitude. It is present in disturbance, seen in Schizophrenia. hypomanic states and in certain organic state. Ex: 6. Ambivalence general paresis, multiple sclerosis and in frontal lobe tumor. It means existence of contradictory feeling, attitudes toward the same object or person. Both of these conflicting attitudes B. Elation: patient feels overjoyed. Self-confidence are faces of the same coin, while only one may be visible, the radiates from him. Elation is often labile and readily other is nevertheless present. Ex: feeling of love and hate shifts to irritability. It is accompanied with increased towards the parents. activity. C. Exhalation: there is an intense elation accompanied by 7. Depersonalization an attitude of grandeur. It is an affective disorder in which feelings of unreality and a D. Ecstasy: Its a feeling of extreme joy and tranquil sense loss of ones own identity are experienced. The unreality of power. It can occurs in dissociative epileptic, symptoms are of two kinds; a) feeling of changed personality Schizophrenic and affective reactions. b) a feeling that the outside world is unreal. Patient feels that he is no longer himself but he does not feel that he has become2. Depression someone else.it occurs in hypochondria, obsessional statesIt is an effective feeling tone of sadness. It is the commonest and hysteriatype of complaint in psychiatric patient. It can vary from milder DISTURBANCES OF ATTENTIONdepressive syndrome to deeper depression. In milderdepressive syndrome the patient is quiet, restrained, inhibited, Organism examines the external world for useful data is knownunhappy, pessimistic has feeling of inadequacy and as attention.hopelessness and the same feelings are in extreme form indeeper depression. 1. Disordered attentionGrief: it is an effect of sadness due to loss of a close relation, Fatigue toxic states and organic lesions interfere and lowermay be death of a person. attention. 11
  12. 12. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing2. Distractibility a) Registration: it means reception of the mental impression The inability to hold attention for a sufficient length of time is called distractibility. In Schizophrenia the degree of b) Retention: it means preservation of the previous by attention is greatly diminished. acquired impression.DISORDERS OF CONSCIOUSNESS c) Recall: It means reproduction of the impression.Impairments in consciousness from least to the greatest are The following are the disorders of memory arestates of confusion, clouding of consciousness, delirium, 1. Hypermnesia: Its an exaggerated degree of retentiondream and fugue states to complete stupor. and recall. It occurs in mild manic states, paranoia and1. Confusion: It is a disturbance of consciousness catatonia impressions with which strong emotions are characterized by bewilderment, perplexity, disorientation, attached. disturbance of associative functions and poverty of ideas. 2. Amnesia: It means loss of memory or inability to recall It occurs in diffuse impairment of brain tissue functions past experience. It can occur in physiological associated with toxic, infections or traumatic agents. disturbances of neurons through chemical alterations2. Clouding of consciousness: It is a disturbance in which or trauma. In psychogenic amnesia, recall is not present clear mindedness is not complete because of physical or for psychogenic reasons. chemical disturbances producing functional impairment The types of amnesia are of the associative apparatus of cerebrum. A. Anterograde amnesia: confined to recent events and is3. Delirium: It is also designated as the acute brain progressive. syndrome. It consists of much more than clouding of consciousness. Delirious reactions occur in infective B. Retrograde amnesia: involves the past events and is not states, puerperial psychoses. progressive.4. Dream state: This is also called twilight state. There is 3. Paramnesia: It is a falsification of memory as well as consciousness disturbance and patient is not aware of distortions of memory also serves as protection against his surroundings. intolerable anxiety. There are various types as follows:5. Stupor: In this patient is motionless and mute but with A. Confabulation: the patient fills the gaps in his memory relative preservations of conscious. Movement of eyes and by fabrications which are without any basis of fact. This is respiration occur. It can occur in toxic-organic brain seen in senile psychoses and particularly in Korsakoffs disease, intense apathy, profound depression blocking, syndrome. epilepsy and dissociative reaction to overpowering fear. B. Retrospect falsifications: These are illusions of memory,DISORDERS OF ORIENTATION created in response to affective needs. It means unconsciously selecting the memories which suit ourThe process by which one understands his surroundings and interests.locates himself in relation to it is known as orientation. If aperson knows his position in reference to time, place and 4. Déjà vu: This is an experience of seeing with the feelingperson, he is said to be oriented. Disorientation may occur in that one has seen it before but does not know when andorganic brain syndromes and in acute conflicts. where. This is seen in Schizophrenia, Psychoneuroses, lesions of the temporal lobe including epilepsy and statesDISORDERS OF MEMORY of fatigue or intoxication.The function by which information is acquired and presented Conclusion:to consciousness and attention is stored, later same isrecalled to consciousness is known as memory. It has three Psychiatric symptoms are difficult to identify yet once identifiedprocesses. it forms as the basis of the patients treatment. Therefore, it is crucial on the part of the nurse to know about it. Reference : 1. Gail W. Stuvart and Michele T. Laria. Principles and Practice of Psychiatric Nursing, 8th Edn. Elfvier New Delhi, 2005, 35-38. 2. Lalitha K. Mental Health and Psychiatric Nursing - An Indian Perspective, 1st Edn. VMG Book House, 147-149. 12
  13. 13. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT-4 MENTAL STATUS EXAMINATION Dr. Sailaxmi Gandhi Assistant Professor, Department of Nursing, NIMHANS, Bangalore - 29The mental status examination (MSE) is a standardized rapport can be established and does the client maintainprocedure where the primary purpose is to gather more adequate eye contact.objective data to be used in determining etiology, diagnosis, 1.3 Overt behaviour and Psychomotor activity (PMA):prognosis, and treatment, and to deal immediately with any Psychomotor activity (PMA) can be simply termed as goalrisk of violence or harm (Kneisl, Wilson Trigoboff, 2004). directed activity. PMA can be increased, decreased or normal.Definition: The MSE is the part of the clinical assessment that There can be psychomotor retardation; aimless, purposelessdescribes the sum total of the examiners observations and activity; restlessness, wringing of hands, pacing; gestures,impressions of the psychiatric patient at the time of the interview twitches, stereotyped behaviour (repetitive, fixed pattern of(Kaplan Sadock, 1998). physical action). Catatonic phenomena such as excitement, stupor, rigidity, posturing, mutism, etc. should be noted andUses: The MSE is very useful to the psychiatric nurse. Some recorded.of these uses are: 2.SPEECH: 1) It helps formulate the nursing diagnosis after identifying the clients problems Speech can be described in terms of quantity, rate of production and quality. One has to note whether the client speaks 2) It helps the nurse teacher to teach nursing students spontaneously, amount of speech, tone, tempo, reaction time, about the psychiatric clients symptoms of illness prosody and whether the speech is relevant and coherent. 3) It can be used to test effectiveness of various nursing 3. THOUGHT: interventions on the psychiatric client. Thought can be assessed under the following components 4) It helps to assess changes in the psychiatric client such as - during various stages of nursing interventions 3.1 Form: This is the way a person puts together ideas and 5) It helps the nurse to assess when the client is fit for associations, i.e. the form in which a person thinks. There discharge and to prepare the client for community life may be rapid thinking, which, when carried to the extreme, isA The format for writing up the MSE may vary slightly depending called as flight of ideas. There may be incoherenton the organization. However, the format must contain certain connections of thoughts (word salad), association by rhymingcategories of information, which is included as follows: (clang associations), etc.1 GENERAL BEHAVIOR: 3.2 Stream: This is best described as flow of thought, train of1.1 Appearance: This is a complete and accurate description thought or continuity of thought. E.g. Loosening of association,of the clients physical characteristics, apparent age, manner blocking, circumstantiality, tangentiality, perseveration, etc.of dress, use of cosmetics, personal hygiene, and responses 3.2 Possessions: These could be thought alienation - thoughtto the examiner. One has to include posture, gait, gestures, insertion (the client describes insertion of strange thoughtsfacial expression, tics, mannerisms, poise, etc. (A tic is an which do not belong to him), thought withdrawal (the clientinvoluntary, spasmodic motor movement. A mannerism is an describes a feeling of emptiness in the head as he feelsingrained, habitual, involuntary movement.). Signs of anxiety thoughts being removed), and thought broadcast (clientto be noted are tense posture, increased sweating, wide eyes, describes a strange situation where all his thoughts aremoist hands, etc. broadcast in the TV, radio, etc.). Obsessions may be elicited1.2 Attitude towards examiner: The clients attitude towards which are pathological persistence of an irresistible thoughtthe examiner may be described as co-operative, friendly, or feeling that cannot be eliminated from consciousness byattentive, interested, seductive, defensive, perplexed, apathetic, logical effort. When these are present, clarify the nature ofhostile, playful, ingratiating, evasive or guarded. Check if compulsive acts - checking, counting or washing and whether 13
  14. 14. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingthey are controlling or yielding. Phobias may also be present. Assessment is done by asking the following questions:These are persistent, irrational, and usually pathological dread a) Have you ever heard voices when no one was aroundof a specific stimulus resulting in a compelling desire to avoid or sounds that no one else could hear?the stimulus. b) Have you experienced any strange sensations in your3.3 Content: Disturbances here include preoccupations body that others do not seem to experience?(which may involve the clients illness), antisocial urges,hypochondriacal and somatic symptoms, and depressive c) Have you seen things that others do not seem to see?ideation (ideas of worthlessness, guilt, hopelessness and 5.2 Types of Hallucinations: Command hallucinations: Falsesuicidal ideas and delusions. Delusions are firm, fixed and perception of orders that a client may feel obliged to obey, Firstfalse beliefs out of keeping with the clients cultural background. person hallucination: False perception of hearing an echo ofSome common delusions are delusion of poverty i.e.a persons ones own thoughts, Second person hallucinations: Falsefalse belief that he or she will be deprived of all wealth, delusion perception of hearing two voices talking to the client, Thirdof persecution i.e. a false belief that he or she is being harmed person hallucinations: False perception of hearing manyor persecuted, delusion of grandeur i.e. a persons voices discussing about the client or in the form of a runningexaggerated conception of his or her importance, power or commentary, De- personalization: A persons subjective senseidentity, etc. of being unreal, strange or unfamiliar, De-realization: A4. MOOD: subjective sense that the environment is strange or unreal.Mood is defined as a pervasive and sustained emotion thatcolours the persons perception of the world (Kaplan Sadock, 6. COGNITIVE FUNCTIONS:1998). Mood should be assessed by both subjective reportand objective evaluation. Various components should be Here clinical assessment includes the areas of -described such as quality of emotion e.g. Happiness, 6.1 Orientationsadness, anxiety, anger, fear, etc., range of mood which can 6.2 Attention Concentrationbe broad where the person is able to experience all moodstates or blunted, constricted and flat (with gradual decrease 6.3 Memoryin emotional expression with absolutely no expression in flat 6.4 Intelligenceaffect), lability of mood i.e. rapid and sudden shifts in emotionfrom one emotional state to the other, reactivity i.e. changes in 6.5 Abstractionemotion in relation to environmental factors, congruity i.e. 6.6 Judgementemotional expression in relation to thought processes (e.g.Smiles while talking about success in exams) and 6.7 Insightappropriateness i.e. emotional expression in relation tosituations (E.g. Laughing during a funeral is inappropriate 6.1 Orientation: Orientation is tested with respect to time,while crying during a funeral is appropriate). place and person5. PERCEPTION: 6.2 Attention Concentration: One has to test whetherThe client may experience perceptual disturbances, such as attention can be aroused and sustained.hallucinations, illusions, depersonalization and derealization.Hallucinations are false sensory perceptions occurring in theabsence of a real stimulus. One should always specify the Tests used in the clinical situation include:sensory modality involved (auditory, visual, olfactory, tactile, 6.2.1 The digit span testgustatory) when hallucinations are experienced and alsodescribe the content of the hallucinations. With respect to 6.2.2. Serial subtractionauditory hallucinations, always enquire whether the 6.2.3 Days or months forward to backwardhallucinations are verbal/non-verbal, continuous/intermittent,single voice/multiple voices, familiar/unfamiliar, pleasant/ 6.2.1 Digit span test:unpleasant, whether commanding, abusive or threatening, a) Forward: The client is given the following instructions: Imood congruent/mood incongruent and first person/second will be saying some digits, listen to me carefully. When I finishperson or third person. saying them, you will have to repeat them in the same order. 14
  15. 15. Booklet on Psychiatric Nursing Skills toTeachers of School of NursingThe examiner after instructing the clients, gives an example Inference is noted as comprehension is good or bad.for digit forward (e.g. If I say 3,7; you say 3,7) and for digit 6.4.3 Arithmetic: Tested by asking the client to solve simplebackward ( e.g. if I say 2, 5; you should say 5, 2) The digits to complex problems in addition, subtraction, division andforward/backward score is the highest number of digits multiplication. Illiterate clients can be asked questions suchcorrectly recalled forward/backward after a maximum of two as - How many tsp. of sugar and tea leaves are required totrials. make tea for 5 persons?6.2.2 Serial Subtractions: Increasingly difficult tests are Inference is recorded as - arithmetic is good, average or bad.presented. The examiner 6.5 Abstraction: Abstract thinking is the ability to deal with 1. Instructs the client concepts. 2. Gives an example of how to perform the task 6.5.1 Can the client explain similarities between a dog and a 3. Notes the responses verbatim lion? 4. Notes the time taken in seconds 6.5.2 Can the client state the difference between cinema and radio?Task Correct response Time limit 6.5.3 The client is asked if he knows what a proverb is and to20-1 20 to 0 15 secs state one with the meaning. Then the examiner states a40-3 40,37,31, etc 60 secs. proverb and asks for the meaning.100-7 100,93,86,79, etc. 120 secs. The clients response is to be noted verbatim. Inference is made as abstraction present at concrete level (when specific explanation is given) or concrete and abstract level (when both6.2.3 Days or months may be asked for in backward or forward specific and abstract explanations are given).order. 6.6 Judgement: Is assessed in the following areasThe inference is recorded as attention can be aroused andsustained. Concentration is good, average or poor 6.6.1 Personal: Enquire about the clients future plans6.3 Memory: Memory functions are divided into immediate, 6.6.2 Social: Observe the clients behaviour in social situationsrecent and remote. Memory impairment can occur in different or ask how he would dress up for a funeral/wedding?types of schizophrenia, psychosis, depression, dementia, etc.Assessment includes immediate, recent and remote memory 6.6.3 Test: Present the following two problems to the client in a manner in which he can comprehend:6.3.1 Immediate memory - Tested by the digit span test6.3.2 Recent memory - Is tested by enquiring about what the a) Fire problem: What will you do if your house catches fire?client had for breakfast, events of the day and what he ate the b) Letter problem: What will you do if you see an addressed,previous night, etc. sealed and stamped envelope which someone had dropped6.3.3 Remote memory - Test by asking for information on life when you are walking on the roadside?events Inference may be - Personal/Social/Test judgement is intactInference may be noted as follows - eg. Recent memory is or impaired.intact or impaired 6.7 Insight: Insight is the clients degree of awareness and6.4 Intelligence: understanding about being ill.6.4.1 General information: Question the client according tothe educational level and background of the client. Common The level of insight with the inference is as given below:questions can be- Name of the Prime Minister, major cities of a) Complete denial of illness (Insight is absent)India, etc. b) Recognizes the presence of illness but gives explanationInference may be noted as follows - General information is in physical terms i.e. headache, fever, etc. (Insight is partial)adequate or inadequate or average6.4.2 Comprehension: Ask questions of increasing difficulty c) Fully realizes the emotional nature of his/her illness, causeranging from Eg. What will you do when you feel cold? -------- of the symptoms and feels he/she requires treatment (Insight is present)------ to--- Why should we be away from bad company? 15
  16. 16. Booklet on Psychiatric Nursing Skills toTeachers of School of NursingB. MINI MENTAL STATUS EXAMINATION (MMSE) 5.4 Read and perform the command Close your eyes (1)MMSE is a bed-side screening test which is not timeconsuming and is a formal evaluation of cognitive impairment 5.5 Write any sentence (check subject, verb, object)in the client. It is also a practical clinical examination to track (1)the changes in the clients cognitive state. It is used as a 6. Construction Total score = 1clinical test in mental disorders occurring due to a generalmedical condition, such as delirium, dementia, amnestic 6.1 Copy the design belowdisorders, etc.The MMSE Questionnaire (Folstein M.F., Folstein S, McHugh Total MMSE score = 30P.R.; 1975) is as follows: Inference of score:1. Orientation (Score 1 if correct) Total score = 101.1 Name this hospital or building1.2 What city are you in now? 25 - 30 = Suggests no impairment1.3 What year are you in now? 20 - 25 = Suggests impairment1.4 What month is it? 20 = Indicates definite impairment1.5 What is the date today?1.6 What state are you in? C EXAMINATION OF NON-COOPERATIVE OR STUPOROUS1.7 What country is this? CLIENTS (Kirby, 1921):1.8 What floor of the building are you on? It may be difficult to get information from non-cooperative or1.9 What day of the week is it? stuporous clients. However, this can lead to delay in assessing the clients problems, formulating nursing diagnosis and1.10 What season of the year is it? planning nursing care. Hence, to avoid this, this format can be followed to assess the mental state of such clients.2. Registration (Score 1 for each object correctly repeated) 1. General reaction and posture:Total score = 3 1.1 Attitude is voluntary or passive2.1 Name 3 objects and have the client repeat them Score the 1.2 Voluntary posture is comfortable, natural, constrainednumber repeated by the client. Name the three objects several or awkwardmore times if needed for the client to repeat correctly (recordthe number of trials----) 1.3 What does the client do if placed in awkward or uncomfortable positions? 1.4 Behaviour toward physicians and nurses is resistive,3 Attention Calculation Total score = 5 evasive, irritable, apathetic or compliant3.1 Subtract 7 from 100 in serial fashion to 65. Maximumscore = 5 1.5 Spontaneous acts: any occasional show of playfulness, mischievousness or assaultiveness. Defence movements when interfered with or when pricked with4.Recall Total score = 3 pin. Eats and dresses self. Pays attention to bowel and bladder.4.1 Do you recall the 3 objects named before? 1.6 To what extent does the attitude change? (Score 1 for each object named correctly)5. Language tests (Total score = 8) II Facial Expression:5.1 Confrontation naming = watch, pen (2) Alert, attentive, placid, sulky, scowling, perplexed, distressed,5.2 Repetition = No ifs, ands, or buts (1) etc.5.3 Comprehension = Pick up the paper in your right hand, Any change of facial expression or signs of emotion - tears,fold it into half, and set it on the floor (3) smiles, flushing, perspiration? On what occasion does this change occur? 16
  17. 17. Booklet on Psychiatric Nursing Skills toTeachers of School of NursingIII Eyes: VII Speech:Open or closed. If closed, does he resist having the lid raised? Any apparent effort to talk, lip-movements, whispers,Movement of eyes absent or can be obtained on request? movements of head?Rolling of eyeballs upward. Blinking, flickering, or tremors of Note exact utterances with accompanying emotionallids. reaction (may indicate hallucinations)Reaction to sudden approach to threat to stick pin in eye.Sensory of pupils (reacts equally) VIII Writing:IV Reaction to what is said or done: Offer paper and pencil. Unresponsive or partially stuporous clients will often write when they fail to talk.Shows tongue when commanded to do so, moves limbs grasps with hand when asked to do so.Reaction to pin-pricks Conclusion: It is of paramount importance that all nurses working with psychiatric patients should know, understandV Muscular reactions: and be skilled in mental status examination. This tool is an Test for rigidity, muscles are relaxed or tense when asset to all nurses as it aids in diagnosing, formulating nursing limbs or body is moved. interventions, observing changes and evaluating care. A Test for negativism shown by movements in opposite nursing teacher also is benefited in that mental status direction or springy or cog-wheel resistance. examination is not only a clinical tool but also a teaching tool. It helps the teacher in demonstrating on the patient how to Test head and neck by movement forward and backward assess presence of psychiatric symptoms. GNM level as well as to side students gain expertise when they return demonstrate this Test also the jaw, shoulders, elbows, fingers and the skill to the teacher. Proficiency in this area will further help lower extremities them to identify and refer psychiatric problems in patients when they work in the general hospitals, the community, schools, Does distraction or command influence the reactions? etc. Teachers teaching psychiatric nursing should definitely Is there closing of mouth, protrusion of lips, holding of gain clinical skills which will help their teaching to be effective! saliva, drooling, etc.VI Emotional responsiveness: References: Is feeling shown when talked to about family or children? 1. Folstein MF, Folstein S, Mc Hugh PR, Mini-Mental State: Or when sensitive points in history are mentioned or A Practical method for grading the cognitive state of when visitors come? patients for the clinician, J.Psychiatr Res 12:189, 1975 Note whether or not acceleration of respiration or pulse 2. Kaplan.I.Harold, Sadock. J. Benjamin, Synopsis of occurs. Also look for flushing, perspiration, tears in Psychiatry: Behavioural Sciences/Clinical Psychiatry, eyes, etc. Do jokes elicit any responses? B.I.Waverly Pvt. Ltd. , New Delhi, VIIIth Edition, 1998 Effect of unexpected stimuli (clap hands, flash of electric light) 17
  18. 18. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing UNIT - 5 PHYSICAL NEUROLOGICAL EXAMINATION Dr. Ramachandra Associate Professor Dept. of Nursing NIMHANS , Bangalore-29Introduction: Moisture-dry, wet or moist?Assessment is an important component of nursing process. Motion-still or vibrating?A complete nursing assessment includes both the collection Consistency of structures-solid or fluid filled?of subjective data and objective data. The complete healthhistory is performed to collect as much subjective data abouta client as possible. Objective data include information about iii) Percussion:the client that the nurse directly observes during interaction Percussion involves tapping fingers or hands quickly andwith him and information elicited through physical assessment sharply against parts of the patients body, usually the chest ortechniques. abdomen. The technique helps to locate organ borders, identify1. Physical Examination: organ shape and position and determine if an organ is solidFour basic techniques must be mastered before professional or filled with fluid or gas.can perform a thorough and complete assessment of the Percussion requires a skilled touch and trained ear to detectclient. By using a systematic approach, examiner will less slight variations in sound. Organs and tissues, depending onlikely to forget an area. their density, produce sounds of varying loudness, pitch andFour techniques used are: duration. For instance, air-filled cavities, such as the lungs,i) Inspection. produce markedly different sounds than do the liver and other dense tissues.ii) Palpation.iii) Percussion. The examiner has to move gradually from areas of resonance to those of dullness and them compare sounds. Also, compareiv) Auscultation. sounds on one side of the body with those on the other side. iv) Auscultation:i) Inspection: Auscultation, usually the last assessment step, involvesInspection involves vision, smell and hearing to observe listening for various breath, heart and bowel sound with anormal conditions and deviations. Performed correctly, stethoscope. To prevent the spread of infection amonginspection can reveal more than other techniques. patients, clean the hearts and end pieces of the stethoscopeInspection begins from first meeting with the patient and with alcohol or a disinfectant after every use.continues throughout the health history and physical 2. Historyexamination. As the examiner assess each body system,observe for color, size, location movement, texture, symmetry, A thorough and accurate history of a neuro patient is often veryodor, and sounds. helpful in assessing their condition. The character of symptoms, distribution, temporal profile of symptoms,ii)Palpation epidemiological associations are often needed in detail inPalpation required examiner to touch the patient with different neurological patients in comparison to other general diseases.parts, using varying degrees of pressure. To do this, examiner The fact that in neurological patients their cerebral dysfunctionneed short fingernails and warm hands. Always palpate tender may limit or distort the account of history third party sources ofareas last. Information about the purpose of touch to different information are most often needed.parts is essential. 3. Neurologic ExaminationEvaluation of the following features are required: Neurological assessment is one of the key components of Texture-rough or smooth? nursing practice. It plays a pivotal role in localization of the Temperature-warm, hot or cold? problem. It encompasses history collection, and the physical examination. Observation is the most important key for 18
  19. 19. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursingneurological assessment. The exam ination requires skill and Make a note of the age, height, build and weight. Is thepatience, from the examiner. patient obese or cachectic?A thorough neurologic examination may take 1 to 3 hours; Check the vital signs including temperature, pulse,however, routine screening tests are usually done first. If the respiratory rate and blood pressure.results of these tests raise questions, more extensive Level of consciousnessevaluations are made. Three major considerations determine Glasgow coma scale is an objective method to assess thethe extent of a neurologic examination: level of consciousness in the patients with neurological a. The clients chief complaints disorders. This scale describes conscious level in terms of b. The clients physical condition (i.e., level of eye opening, verbal response and motor response. These consciousness and ability to ambulate), as many parts are having 4, 5, 6 scores each respectively. On examination, of the examination require movement and coordination observer has to assign score to the observed category to each of the extremities parameter. The minimum score is 3 and maximum is 15. c. The clients willingness to participate and cooperate. Eye Opening (E) Verbal Response (V) Motor Response (M) 4= spontaneous 5= oriented 6= obeys commands3.1 Equipments required are 3= to voice 4= disoriented conversation 5= localizes pain 2= to pain 3= non comprehensible 4= withdrawal flexion1. Reflex hammer 1= no response words, 3= abnormal flexion2. 128 and 512 hz tuning forks 2= incoherent sounds decorticate posture 1= no response 2= abnormal extension3. Snellen Chart decerebrate posture4. Pen light 1= no response5. Ophthalmoscope6. Sugar/salt For children under 5, the verbal response criteria are adjusted as follow7. Coffee powder/any scented material8. Disposable safety pin Score 2 to 5 yrs 0 to 23 months appropriate words or9. Tongue depressors 5 smiles or coos appropriately phrases10. Wisps of cotton to assess light- touch 4 inappropriate words cries and consolable persistent cries and/or persistent inappropriate11.T est tubes of hot and cold water for skin temperature 3 screams crying /or screamingassessment grunts or is agitated or 2 grunts restless 1 no response no response3.2 The components of neurological examination includesassessment of: Children with a Glasgow Coma Scale of 3-8 are considered1. Level of consciousness 5.Sensory System. comatose2. Mini Mental Status Exam 6. Deep tendon reflexes 3.4 Mental Status Examination3. Cranial nerves 7.Coordination and balance Evaluation of mental status is a part of the neurological4. Motor System 8. Brain stem reflexes examination. The appearance, behaviour, level of consciousness, attention, concentration, memory, orientation, abstraction, judgement, language and speech are assessed3.3 Assessment of Level of consciousness as discussed in earlier chapterGeneral appearance: 4. Examination of the Cranial NervesNote the patients personal hygiene and dress. Is it appropriate The following is a summary of the cranial nerves and theirfor the environment situation or not respective functioning. 19

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