CRIS LUTHER's ADVANCED HEALTH ASSESSMENT IN PSYCHIATRIC MENTAL HEALTH NURSING

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The course title is: Advanced Health Assessment in Psychiatric & Mental Health Nursing. Nurses in all specialties practice assessment as the first step in the universal approach of problem-solving in …

The course title is: Advanced Health Assessment in Psychiatric & Mental Health Nursing. Nurses in all specialties practice assessment as the first step in the universal approach of problem-solving in nursing, the nursing process. The application of which in Psychiatric Mental Health Nursing has the same goal as it has in other areas of nursing.

Though, the goal of the nursing process in this specialty field is not different as mentioned, the process of assessment is composed of complex concepts the psychiatric mental health nurse must familiarize- theoretically and clinically. This posted a main challenge in the completion of this material.

The student performed repeated accession and elimination of concepts to finalize the contents which are deemed significant and consistent with the course title: Advanced Health Assessment in Psychiatric & Mental Health Nursing.
________________________________________

The text is organized in four parts presenting various approaches in psychiatric assessment. The focus remained on the basic principles of nursing assessment:

Part 1: Assessment of Psychiatric Mental Health Clients, discusses the basic principles of nursing assessment; the topic progresses to assessment procedures specific to the specialty field (M.S.E.), an example was presented to clearly understand its congruence to practice. Related terminologies and discussion of comorbid problems are important tools in identifying actual and potential health problems during client assessment.

Part 2: The DSM-IV-TR, An Essential Tool for Assessment and Diagnosis of Psychiatric-Mental Health Clients, presents vital components of this universal tool in diagnosing mental illnesses.

Part 3: Assessment Factors in Dual Diagnosis, addresses the need to thoroughly assess other equally significant problems that co-exist with the diagnosed primary mental illness. The co-existence of substance abuse is the commonest in dual diagnosis.

Part 4: Formulation of Assessment-based Care Plan. The nursing process has been referred to as an ongoing systematic series of actions, interactions and transactions. Hence, the inclusion of the entire process is a must to fully appreciate the essentiality of an assessment that is done in congruence with standards.

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  • 1. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 1 Mental Health & Psychiatric Nursing 1: ADVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, B.S.N.,R.N. Master of Arts in Nursing Major in Psychiatric and Mental Health Nursing DR. EMILIO ALVAREZ Professor Philippine Colleges of Health Sciences, Inc., Manila School of Graduate Studies Android/ iOS
  • 2. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 2 About the cover: “Introspection” (oil on canvass, 2003) “The one who has conquered himself is a far greater hero than he who has defeated a thousand times a thousand men.” ― Gautama Buddha, The Dhammapada: The Sayings of the Buddha _______________________________________ Self-awareness refers to the ability to recognize the nature of one’s own attitude, emotions and behavior. It is an important tool in assessing clients who exhibit mental illness- as one cannot assess another person without introspection. (THE RATIONALE FOR CHOOSING THE COVER) A painting by Gurudev Sri Sri Ravi Shankar (Source: http://artoflivingsblog.com/awareness-the-key-to-happiness/)
  • 3. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 3 - Rationale for Selection of Topics and Organization of Text – The course title is: Advanced Health Assessment in Psychiatric & Mental Health Nursing. Nurses in all specialties practice assessment as the first step in the universal approach of problem-solving in nursing, the nursing process. The application of which in Psychiatric Mental Health Nursing has the same goal as it has in other areas of nursing. Though, the goal of the nursing process in this specialty field is not different as mentioned, the process of assessment is composed of complex concepts the psychiatric mental health nurse must familiarize- theoretically and clinically. This posted a main challenge in the completion of this material. The student performed repeated accession and elimination of concepts to finalize the contents which are deemed significant and consistent with the course title: Advanced Health Assessment in Psychiatric & Mental Health Nursing. ________________________________________ The text is organized in four parts presenting various approaches in psychiatric assessment. The focus remained on the basic principles of nursing assessment: Part 1: Assessment of Psychiatric Mental Health Clients, discusses the basic principles of nursing assessment; the topic progresses to assessment procedures specific to the specialty field (M.S.E.), an example was presented to clearly understand its congruence to practice. Related terminologies and discussion of comorbid problems are important tools in identifying actual and potential health problems during client assessment. Part 2: The DSM-IV-TR, An Essential Tool for Assessment and Diagnosis of Psychiatric-Mental Health Clients, presents vital components of this universal tool in diagnosing mental illnesses. Part 3: Assessment Factors in Dual Diagnosis, addresses the need to thoroughly assess other equally significant problems that co-exist with the diagnosed primary mental illness. The co-existence of substance abuse is the commonest in dual diagnosis. Part 4: Formulation of Assessment-based Care Plan. The nursing process has been referred to as an ongoing systematic series of actions, interactions and transactions. Hence, the inclusion of the entire process is a must to fully appreciate the essentiality of an assessment that is done in congruence with standards.
  • 4. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 4 - Introduction - Psychiatric-mental health nursing involves the diagnosis and treatment of human responses to actual or potential mental health problems. It is a specialized area of nursing practice that uses theories of human behavior as its scientific framework and requires the purposeful use of self as its art of expression. It is concerned with promoting optimum health for society. Comprehensive services focus on prevention of mental illness, health maintenance, management of and referral for mental and physical health problems, diagnosis and treatment of mental disorders (Haber & Billings, 1993). Psychiatric nurses must be able to make rapid comprehensive assessments; use effective problem-solving skills in making complex, clinical decisions; act autonomously as well as collaboratively with other professionals; be sensitive to issues such as ethical dilemmas, cultural diversity, and access to psychiatric care for undeserved population; be comfortable working in decentralized settings ; and be sophisticated about the costs and benefits of providing care within fiscal constraints (ANA, Statement on Psychiatric-Mental Health Clinical Nursing Practice, 1994,p7). My definition of psychiatric-mental health nursing is based on my personal experience- which is: “A detour from the ordinary; a specialty field for nurses who have discovered that they are by nature empathic. Nurses in this specialty field are professionals who understand the complexes of human behavior that guides them to respect the uniqueness of every individual. Their ability to maintain composure in trying situations is almost infinite!” When I applied at the PCHS Graduate School enrolling in M.A. with Tracks in Psychiatric Mental Health Nursing- I was asked about my option to pursue the major since I was a lone enrollee in this track. I have long contemplated pursuing this major considering that this is my area of interest and is consistent with my professional and academic performances. With the guidance of my chosen institution to pursue my degree- the PCHS Graduate School, ultimately, I envision myself as a Forensic Nurse in the future. The Student About the Compilation This material is a compilation of various information on generally acceptable knowledge, concepts, principles, theories and practices in PSYCHIATRIC AND MENTAL HEALTH NURSING. It adapts contents from various publicly acknowledged publications, authors, theorists, authorities and practitioners whose works are commonly utilized in the academe and practice, and are frequently-tested competencies locally and abroad. The works of these authors, theorists, authorities and practitioners are indispensable in learning PSYCHIATRIC AND MENTAL HEALTH NURSING as they are indispensable in the completeness of this compilation. Care has been taken to confirm accuracy of the information presented and describes generally accepted practices. However the student who prepared this material is not responsible for errors or omissions or for any consequences from application of the information in this compilation. The primary goal of the student is to familiarize concepts in the subject ADVANCED HEALTH ASSESEMENT IN PSYCHIATRIC AND MENTAL HEALTH NURSING based on the COURSE DESCRIPTION provided by the PCHS-Graduate School with the guidance of his Graduate School Professor DR. EMILIO ALVAREZ. It is not intended for commercial publication and resources were acquired legally. It is his great pleasure that this compilation be reproduced for reference of other students aiming to thoroughly understand ADVANCED HEALTH ASSESEMENT IN PSYCHIATRIC AND MENTAL HEALTH NURSING.
  • 5. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 5 - Table of Contents - Part 1: Assessment of Psychiatric Mental Health Clients, p.4 Overview of Client Assessment Initial Patient Assessment Mental Status Examination Ongoing Assessment Discussion of Essential Terminologies Comorbid Problems in Assessing Psychiatric-Mental Health Clients Part 2: The DSM-IV-TR, p.14 An Essential Tool for Assessment and Diagnosis of Psychiatric-Mental Health Clients Overview of the DSM-IV TR Components and Axes of the DSM-IV TR Major Psycho-Diagnostic Features of the DSM – IV-TR Differential Diagnosis Advantages and Disadvantages of utilizing the DSM IV Socio-cultural Implications Part 3: Assessment Factors in Dual Diagnosis, p.19 Defining Dual Diagnosis Dynamics of Dual Diagnosis Screening and Assessment Part 4: Formulation of Assessment-based Care Plan, p.22 Nursing Diagnosis Outcome Identification Planning and Intervention Evaluation
  • 6. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 6 Part 1. Assessment of Psychiatric Mental Health Clients The use of the nursing process has the same goal in psychiatric nursing as it has in other areas of nursing: patient-centered, goal directed action that facilitates health promotion, primary prevention, treatment and rehabilitation. “The nursing process is the foundation of clinical decision making and encompasses all significant action taken by nurses in providing developmentally and culturally relevant psychiatric mental health care to all patients”. (ANA,2000) Overview of Client Assessment______________________________________________________________ The first step in the nursing process is crucial. Assess the client in a holistic way, integrating any relevant information about the client’s life, behavior and feelings. The focus of care, beginning with assessment, is toward the client’s optimum level of health and independence. (Schultz and Videbeck, 2002) The assessment phase includes collection of data about a person (child, adolescent, adult or older client), family or group by methods of observing, examining and interviewing. The type of assessment depends on the client’s needs, presenting symptoms and clinical setting (eg.: an adolescent client who attempts suicide may be assessed in the emergency room, or an older adult may be assessed in a nursing home to rule out the presence of major depression secondary to a cerebrovascular accident). Types of Data Two types of data are collected:  Objective Data are measurable and tangible data collected during a physical examination by inspection, palpation, percussion and auscultation. Vital signs and laboratory results also fall in this category.  Subjective Data are obtained as the client, family members or significant others provide information spontaneously during direct questioning or during the health history. Review of past medical history and psychiatric records are considered to be subjective and it involves interpretation by the nurse. Types of Assessment Three kinds of assessment exist:  Comprehensive Assessment includes data related to the client’s biologic, psychological, cultural, spiritual and social needs. It is generally completed in collaboration with health care professionals such as physician, psychologists, neurologist and social worker.  Focused Assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member or a crisis situation (eg.: in the event of suicide, the nurse would assess the client’s mood, affect and behavior; data regarding past attempted suicide would also be collected).  Screening Assessment includes the use of assessment rating scales to evaluate data regarding a particular problem (eg.: Hamilton Rating Scale for Depression). During any assessment, the psychiatric-mental health nurse uses a psychosocial nursing history and assessment tool to obtain factual information, observe client’s appearance and behavior and evaluate client’s mental or cognitive status. Initial Patient Assessment_____________________________________________________________ This phase begins on admission to a unit or program with a nurse. Each psychiatric unit, clinic and program has its own version of an intake or nursing assessment form. Be aware that although, a newly admitted patient may be “medically cleared,” both physical and mental health assessment should be the focus nursing care. One study found that complete physical examinations were regularly lacking in newly admitted patients with schizophrenia (Szpacowicz and Herd, 2008). Complete vitas signs were documented in only 52% of cases in the same study, whereas no vital signs were recorded in 6% of patients. Typically, the term “medical clearance” indicates that no thorough examination was performed. A multidisciplinary team including at least the nurse, psychiatrist, the psychologist, social worker, pharmacist is the foundation of quality care (Zwarensrtein, et al., 2009). A chaplain also might be incuded on the team to add component os a spiritual assessment (O’Reilly, 2004). The staff nurses uses all information that the team members collect to confirm the patient assessment while minimizing the need for the patient to repeat information. Because most facilities use intake forms or checklist, the result of the
  • 7. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 7 interviews do not have to be written in narrative forms. Critical facts about the patient should be summarized in an admission note; the admission note is intended to aid other practitioners who are asked to see the patient. Mental Status Examination ___________________________________________________________ The mental status examination (MSE) is a very important component of patient assessment in psychiatric settings. The MSE focuses on the patient’s current state in terms of thoughts, feelings and behaviors. The categories of the MSE help organize a summary of the information gathered during the initial patient assessment. Categories Information General appearance Type, condition and appropriateness of clothing (for age, season, setting), grooming, cleanliness, physical condition, posture Behaviors during the interview Degree of cooperation, resistance and engagement Social skills Friendliness, shyness or withdrawal Amount and type of motor activity Psychomotor agitation or retardation, restlessness, tics, tremors, hypervigilance or lack of activity Speech patterns Amount, rate, volume, tone, pressured speech, mutism, slurring or stuttering Degree of concentration Attention span Orientation To time, place, person, person, situation and level of consciousness Memory Immediate recall, recent, remote, amnesia and confabulation Intellectual Functioning Educational level, use of language and knowledge, abstract versus concrete thinking (proverbs) and calculations (serial sevens) Affect Labile, blunted, flat, incongruent or inappropriate Mood Specific moods expressed or observed- euphoria, depression, anxiety, anger,guilt or fear Thought clarity Coherence, confusion, vagueness Thought content Helplessness, hopelessness, worthlessness, suicidal thoughts or plans, suspiciousness, phobias, obsessions, compulsions, preoccupations, poverty of content, denial, hallucinations, (auditory, visual, tactile, gustatory, olfactory) or delusions (of reference, influence, persecution, grandeur, religious, nihilistic, somatic) Insight Degree of awareness of illness, behaviors, problems and their causes Judgment Soundness of problem solving and decisions Motivation Degree of motivation for treatment. Sample Recording of Client, Marlene Aguilar The nurse introduces himself to Marlene Aguilar and led the way to the office, walking slowly but slightly ahead of the patient. The patient follows without looking at the nurse. In the office, the nurse sits in a chair at a desk and opens a folder of papers. The patient sits in a chair at the side of the desk, holding her purse with both hands on her lap. Nurse Patient Analysis Verbal Nonverbal Verbal Nonverbal Themes Therapeutic Techniques “What do you prefer to be called?” Has pen in hand, other hand is flat on desk, is looking at patient. (pause) “Marlene.” Looking at the floor. Content- oriented to person. Questioning, active listening “Marlene, we will be better able to help you if we know more about you. What has happened in your life recently?” (same as above) (pause) “ I could not get out of bed (pause). I was so tired.” Is turning head slightly, still looking at the floor; is not smiling or frowning. Content- describes fatigue and effects. Mood- sadness Interaction- opens up with nurse. Giving information, questioning “How long have you been feeling Is writing, and then looking at “I do not know. (pause) A week (same as above) Content- unsure of time frames, Placing event in time or sequence,
  • 8. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 8 so tired?” patient. I guess”. marital separation, possible annulment. active listening “What happened a week ago? ” “I can see this is difficult for you to talk about. ” (pause) Leans toward patient. Moves tissue box. Looks at patient; both arms on lap. (pause) “My husband (pause) left.” “That he was fed up.” Tears are in eyes; tries to open purse. Is nodding head; raises eyes slightly; is still not looking at the nurse. Starts to cry; gets tissue. Sobs occasionally. Mood- sadness, guilt. Interaction- in conflict with husband; is more trusting of nurse. Focusing, using empathy and silence, questioning “What did he say when he left?” “What did you say to him?” Leans toward patient. One arm is on lap, the other on arm of chair. (pause) “ That he wanted an annulment.” “I don’t know. I don’t remember”. (pause) “Maybe I asked him to stay.” I crying quietly Content- difficulty describing situations, short- term memory disturbance. Focusing, active listening “Then what happened?” (same as above) “It’s all blur; I think I cried all day.” (same as above) Mood- sadness, guilt. Interactions- abandonment; loneliness Focusing “Who did you talk to?” (same as above) “No one. “ (pause) “My kids are married and gone. I just stayed in bed” Is the same but crying less often Content- did not ask for help; avoidance of divorce issue Mood-sadness Interaction- perceived lack of support. Focusing “When you were feeling so tired, did you have thoughts of killing yourself?” (same as above) (pause) “I was so scared of being alone. I thought I’d rather be dead.” Looks at nurse for the first time; both hands are in lap Content- aware of tears, suicidal ideation but no plan; difficulty with problem solving. Questioning “How did you think about killing yourself?” (same as above) “I couldn’t think of anything, I didn’t know what to do.” Looks at floor again, fumbles in purse. Mood- sadness, depression. Interaction- abandonment; lack of support; open with nurse. Focusing “Are you still thinking about suicide?” Hands patient a tissue “Not really. But (pause) I still wish I were dead. I don’t know what to do.” Blows nose and then puts hands in lap, looks at nurse. Content- minimizing suicidal ideation but ambivalent, helplessness. Mood-sadness Focusing
  • 9. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 9 “While you are here, we are going to help you consider some options about what to do so you won’t feel so alone and scared.” Leans forward. Looks at patient. Both hands on lap. (Silence) Looks at floor; crying has stopped; Looks at nurse Interaction- asking for help Suggesting collaboration, verbalizing implied, active listening “It will help us if I ask you some questions.” Turns back to papers. Is ready to write. Okay. Looks at nurse Giving information MSE with Marlene Aguilar General Appearance Dressed appropriately for seasons, clothes are clean but not depressed ; hair is unwashed and uncombed; slouched shoulders, pale blank expression. Memory Immediate recall: Remembers nurse’s name; Recent: Difficulty organizing sequence but mostly complete, except for last week; Remote: Good detail on birth of children Behaviors during the interview Degree of cooperation, resistance, and engagement: slow to respond but cooperative Intellectual Functioning College education evident in vocabulary; calculations and proverbs were not done; abstract thinking evident in discussion of love and fidelity. Social skills Withdrawn; no unusual habits; reduced socialization; poor eye contacts Affect Blunted Amount and type of motor activity Slowed; crying at times; no tics or tremors noted Mood Depressed; anxiety level is moderate; guilt and covert anger expressed. Speech patterns Amount is reduced with slowed rate and soft tone Thought clarity Clear; coherent Degree of concentration and attention span Decreased concentration; easily distracted by stimuli; slight shortening of attention span Thought content Expressing helplessness; hopelessness and suicidal thoughts without a plan; fears being alone; no evidence of hallucinations or delusions Orientation Aware of person, place and time; responsive Insight Aware of problems in facing divorce but not yet able to describe factors leading to separation Judgment No impairment until last two weeks when she became unable to make decisions, take action or seek support Motivation for treatment Wants help with depression, fatigue and handling divorce; unable to sate what type of help she needs. Some patients are too ill to participate in or complete the assessment interview. In these cases, objective data such as patient behaviors and reports by family members are used. In some cases, information from staff in the outpatient setting that the patient attends is available. During the initial assessment, behaviors can be described without knowing or identifying their causes- for example, anxiety level, degree of withdrawal, thought disturbances reflected in speech, voice tone and general appearance. Causes and dynamics can be elicited later to form a strong basis for treatment plan. Ongoing Assessment _______________________________________________________________ Even when the initial assessment is complete, each encounter with a patient involves a continuing assessment that might or might not be congruent with the initial assessment. No one acts or feels the same way 24 hours a day, seven days a week. The ongoing assessment often involves an investigation of patient’s statements and actions at the moment: “You have been sitting alone for a while?” or “You mentioned being worried; what about?” When the nurse decides to investigate a patient’s specific behavior, exploring the following might be valuable:  Context or situation that precipitated the behavior  Patient’s thoughts at the same time  Patient’s feelings, then and now  Whether the behavior makes sense in that context  Whether the behavior was adaptive or dysfunctional  How this episode fits with the total picture of the patient  Whether a change is needed
  • 10. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 10 Discussion of Essential Terminologies ____________________________________________________  General appearance includes physical characteristics, apparent age, peculiarity of dress, cleanliness and use of cosmetics. Facial expression is a manner of nonverbal communication in which emotions, feelings and moods are related. People who are depressed often neglect their personal appearance, appear disheveled, and wear drab looking clothes that are generally dark in color, reflecting a depressed mood. The facial expression may appear sad, worried, tense, frightened or distraught. Clients with mania may dress in bizarre or overly colorful outfits, wear heavy layers of cosmetics and don several pieces of jewelry.  Affect or Emotional State (the terms affect and emotion are often used interchangeably), the relationship between affect or emotional state and thought processes is of particular importance. - Affect is the outward manifestation of a person’s feelings, tone or mood - Emotional state is expressed objectively on his face, can be widely divergent form what the client says or does; - Apathy is a term that may be used to describe an individual’s display of lack of feeling, emotion, interest or concern. - Affective responses may be:  Appropriate- responses are congruent  Inappropriate- Discordance or lack of harmony between one’s voice and movements with one’s speech or verbalized thoughts.  Labile- Abnormal fluctuation or variability of one’s expressions, such as repeated, rapid or abrupt shifts.  Blunted- Severe reduction or limitation in the intensity of one’s affective responses to a situation.  Restricted or constricted- A reduction in one’s expressive range and intensity of affective responses.  Flat- Absence or near absence of any signs of affective responses, such as an immobile face and monotonous tone of voice when conversing with others. Under ordinary circumstances, a person’s affect varies according to the situation or subject under discussion. The person with emotional conflict may have a persistent emotional reaction based on this conflict. As the examiner or observer, identify the abnormal emotional reaction and explore its depth, intensity and persistence. Such as inquiry could prevent a person who is depressed from attempting suicide. Helpful techniques in eliciting significant information:  A lead question such as “What are you feeling?” (may elicit responses such as “angry”, “frustrated”, “depressed” or “confused”), ask the patient to describe further.  Observe if the patient’s response constant or fluctuate during the assessment.  Record a verbatim response to questions concerning client’s mood and note whether an intense emotional response accompanies the discussion of specific topics.  Behavior, Attitude and Coping Strategies Consider the following behavior and attitude:  Exhibition of strange, threatening, suicidal, self-injurious or violent behavior  Aggressive behavior may be displayed verbally or physically against self, objects or other people. Are they making efforts to control their behavior?  Unusual mannerisms and motor activities- tics, tremors, impaired gait, psychomotor retardation, agitation, pacing (excessively).  Attitude- friendly, embarrassed, evasive, fearful, negativistic, impulsive- such attitude toward the nurse or other people may facilitate or impair the assessment process.  Behavior- overactive or underactive? Purposeful , disorganized or stereotype? Are reactions fairly consistent? If the client is in contact with reality and able to respond to such a question, ask them how they normally cope with a serious problem or with high level of stress- responses would help the nurse to assess the client’s present ability to cope and their judgment. Further assess with the presence of support system or the use of drugs and alcohol to cope (their behavior may be the result of the absence or inadequate support system). Paranoid clients may isolate themselves and appear evasive during a conversation and demonstrate negativistic attitude towards the nurse. The nurse must understand that this is an attempt to protect oneself by maintaining control of a stressful environment.  Communication and Social Skills The manner in which the client talks enables the nurse to appreciate difficulties with thought processes. Hence, verbatim sample of the stream of speech is necessary to be obtained to illustrate pathophysiologic disturbances. Consider the following while assessing the client’s ability to communicate:
  • 11. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 11  Coherence  Flow of speech (logical, illogical, vague, loosely organized)  Rate of speech (slow, rapid, retarded; responds only when questioned)  Volume (whisper, soft, loud/shout)  Delay in answers or break off conversation in the middle of a sentence and refuse to talk further  Repetition of certain words and phrases  Do they make up new words that have no meaning to you/ other people  Use of obscene language  Numerous topics (jumping from one to another)  Stutter or regress in speech  Unusual personality traits interfering with their ability to socialize or adapt with hospitalization- aggressive, domineering, feeling of rejection, appear to be loner or associate freely with others (social skills). IMPAIRED COMMUNICATION Blocking Sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason; this is associated with preoccupation, delusional thoughts or hallucinations. Common in clients with schizophrenia experiencing auditory hallucinations. Circumstantiality Giving too much unnecessary details that delay meeting a goal or stating a point. Common in clients with mania and some clients with some cognitive disorders (early stage of dementia or delirium); also in patients who abuse substances. Flight of ideas Characterized by over-productivity of talk and verbal skipping from one idea to another. Talk is continuous but ideas are fragmentary. Eg.: “Do you ever feel blue? Feelings can change from day to day. The days are getting longer.” Common in manic clients. Perseveration The person emits the same verbal response to various questions; repetitive motor response to various stimuli. Found in client experiencing some cognitive impairment disorders and clients experiencing catatonia. Vergiberation Meaningless repetition of specific words or phrases. Observed in clients with cognitive impairment disorders. Neologism The use of new words or combination of several words coined or self-invented by a person and not readily understood by others. Found in clients with certain schizophrenic disorders. Mutism Refusal to speak even though the person may give indications of being aware of the environment. It may occur due to conscious or unconscious reasons. Observed in clients with catatonia schizophrenic disorders; profound depressive disorders; stupors of organic or psychogenic in origin.  Content of Thought Alteration in thought process may be related to a mood disorder (eg.: depression) or to an organic condition (eg.: dementia). CONTENT OF THOUGHT Delusions Fixed false beliefs not true to fact and not ordinarily accepted by other members of the person’s culture. They cannot be corrected by an appeal to the person experiencing them. Occur in: various types of psychotic disorders (cognitive impairment and schizophrenia and some client with affective disorders). Types of Delusions:  Reference or persecution- believes that he is object of environmental attention or is being singled out for harassment  Alien control- believes that his feelings, thoughts, impulses or actions are controlled by external source  Nihilistic- Denies reality or existence of self, part of self or some external object “I have no head!”  Self-deprecation- Feeling of unworthiness, ugliness or sinfulness  Grandeur- Experiences exaggerated ideas of his importance or identity.  Somatic- Entertains false beliefs pertaining to body image or body function (the client actually believes that he has cancer, leprosy or some other terminal illness). Hallucinations Sensory perceptions that occur in the absence of an actual external stimulus. It occurs in clients with substance-related disorders, schizophrenia and manic disorders.  Auditory (most common)
  • 12. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 12  Visual  Olfactory  Gustatory  Tactile Depersonalization Refers to a feeling of unreality or strangeness concerning self, the environment, or both. Client may feel they are “going crazy”. Causes include prolonged stress and psychological fatigue, as well as substance abuse. Clients with schizophrenia, bipolar disorders and depersonalization disorders have described this feeling. Eg.: “Out of body experience” wherein the client view himself from a feet overhead. Obsessions Insistent thoughts, recognized as arising from the self, absurd and meaningless to the client. However, they persist despite his endeavors to be rid of them. Client with obsessive-compulsive typically experience obsessions. Eg.: “I can’t stop thinking of things”, “I can’t get rid-off these thoughts!” Compulsions Insistent, repetitive, intrusive and unwanted urges to perform an act contrary to one’s ordinary wishes or standards. Client with obsessive-compulsive typically experience obsessions. Eg.: The repetitive urge to gamble although his wife threatened to divorce him is he does not stop to.  Orientation pertains to orientation to time, person and place. Levels of Orientation and Consciousness Confusion Disorientation to person, place or time characterized by bewilderment and complexity Clouding of consciousness Disturbance in perception of thought that is slight to moderate in degree, usually due to physical or chemical factors producing functional impairment of the cerebrum Stupor A state in which the client does not react or is unaware of his surroundings. The client appears to be motionless, mute but conscious. Delirium Confusion accompanied by altered fluctuating consciousness. Disturbance in emotion, thought, and perception is moderate to severe. Usually associated with infections, toxix states, head trauma and so forth. Coma Loss of consciousness  Memory is the ability to recall past events and experiences. Categories of Memory Recent Ability to recall events in the immediate past and for up to 2 weeks previously. Loss of recent memory may be seen in clients with dementia, delirium or depression. Long term Ability to recall remote past experiences such as the date and place of birth; names of schools attended, occupational history and chronologic data regarding previous illness. Loss of long term memory is usually in due to physiologic disorder resulting in brain dysfunction. Memory defects may result from lack of attention, difficulty with retention or recall or any combination of this factors, disorders include:  Hyperamnesia or an abnormally pronounced memory  Amnesia or loss of memory  Paramnesia or falsification of memory  Intellectual Ability is an indication of a person’s ability to use facts comprehensively. This can be assessed by asking general information such as the name of the past three presidents, calculate simple mathematical problem or correctly estimate and form opinions concerning objective matters (Eg.: What would you do if you found a wallet in the hallway?”- the nurse evaluates reasoning ability and judgment by the response given). Abstract and concrete thinking abilities are evaluated by asking the client to explain the meaning of proverbs (eg.: “an eye for an eye, a tooth for a tooth”)  Insight Regarding Illness or Condition Insight is defined as self-understanding, or the extent of one’s understanding about the origin, nature and mechanisms of one’s attitudes and behavior. Relevant questions are:  Does the client consider himself ill?  Does he understand what is happening?  Is the illness threatening to him? Insights into their illness or conditions range from poor to good, depending on the degree of psychopathology present. Insightful clients are able to identify strengths and weaknesses that may affect their response to treatment.  Spirituality involves the client’s beliefs, values and religious culture. Spiritual history is important in evaluating whether these beliefs would help or hinder the client from treatment.
  • 13. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 13  Does the hospitalize client exhibit spiritual anxiety and verbalize a need to connect with his own spiritual support system?  Is the terminally ill client exhibiting a spiritual dilemma regarding the meaning of life and death or the presence of higher power?  To what extent the spiritual issues are pertinent to the client’s current situation?  Are religious beliefs and affiliations served as coping mechanisms?  Sexuality may be a factor with a client for number of reasons. For example, the client is impotent, may have lost a sexual partner or may have been a victim of sexual abuse. The age and sex of the nurse may affect the responses given. Helpful questions that may initiate the topic of sexuality include:  Does the client express any concerns about sexual identity, activity and function?  When did these concerns begin?  Does the client prefer a male or female nurse to discuss these concerns?  Neurovegetative Changes involves changes in psychophysiologic functions such as sleep patterns, eating patterns, energy levels, sexual functioning or bowel functioning.  Depressed clients usually complain of insomnia or hypersomnia, loss or increased appetite, loss of energy, decreased libido and constipation (all signs of neurovegetative changes).  Psychotic clients may neglect nutritional intake, appear fatigued, sleep excessively and ignore elimination habits (sometimes developing fecal impaction). A simple yet valuable question to ask clients is “Do you have difficulty sleeping at night or staying awake during the day?” (It has been estimated that as many as one-third of the clients seen in the primary care setting may experience occasional difficulties in sleeping and 10% of this may have chronic sleep problems (Brown, 1999). Abnormal Sleep Patterns Insomnia Difficulty initiating or maintaining sleep (symptom with many different causes and occurs in often in various psychiatric mental health disorders). Acute/ Primary Insomnia Inability to initiate or maintain sleep or nonrestorative sleep for at least 1 month. It is often caused by emotional or physical discomfort such as chronic stress, hyperarousal, poor sleep hygiene (eg.: drinking coffee at bedtime), environmental noise or jet lag. It is not due to the direct physiologic effects of a substance or a general medical condition. Secondary Insomnia Inability to initiate or maintain sleep or nonrestorative sleep due to a psychiatric disorder such as depression, anxiety or schizophrenia; general medical or neurologic disorder; pain; or substance abuse. Comorbid Problems in Assessing Psychiatric-Mental Health Clients________________________________  Medical Issues Clients with medical problems commonly present with clinical symptoms of a comorbid psychiatric-mental health disorder. Thus, communication and collaboration among nurses, doctors and other clinicians is critical. Comorbid depression with various medical illnesses such as cardiovascular disease, stroke or Parkinson’s disease can impede medical treatment and increase mortality if the depression is not identified.  Pain A major yet largely avoidable health problem is considered a multidimensional experience that potentially affects the individual physically, emotionally, spiritually and socially. Initially pain is assessed using pain rating scale appropriate to the client’s age and ability to communicate. This baseline pain assessment is used for comparison with all future assessments. Self-report of pain is the most reliable and valid pain assessment tool. If the client is unable to communicate, data are obtained by observing behavior, obtaining proxy reports from family or significant others, or by documentation of physiologic parameters.  Physiologic Reponses to Medication It is important to assess the potential adverse effects of various medications that could precipitate client’s emotions, behavior or mental status. It requires that a nurse should carefully recognize potential or present effects of the client’s drug therapy (Eg.: A patient diagnosed with Parkinson’s disease with comorbid depression on carbidopa (Sinemet) for 3 months visits the clinic for supportive therapy complains of confusion, disorientation and visual hallucinations. After reassessing the client to rule out clinical symptoms of clinical depression, the nurse educates the client about the potential side effects of carbidopa and documents the patient’s physiologic responses to medication).
  • 14. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 14 Part 2 The DSM-IV-TR: An Essential Tool for Assessment and Diagnosis of Psychiatric-Mental Health Clients Overview of the DSM-IV TR___________________________________________________________________ The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the standard for classifying mental disorders that are used by mental health professionals in the United States and is adopted in various parts of the world. It is intended to be applicable in a wide variety of contexts and used by clinicians and researchers of many different orientations (For example; biological, psychodynamic, cognitive, behavioral, interpersonal, family/systems). The DSM IV has been designed for use across settings such as inpatient, outpatient, partial hospitalization, consultation-liaison, clinic, private practice and primary care. Professionals that use the DSM diagnosis are psychiatrists, psychologists, social workers, nurses, occupational and rehabilitation therapists, counselors and other health and mental health professionals. The DSM is also a necessary tool for collecting and communicating accurate public health statistics. Components and Axes of the DSM-IV TR_________________________________________________________ The DSM consists of three major components: the diagnostic classification, the diagnostic criteria sets and the descriptive text.  Diagnostic Classification The diagnostic classification is the list of the mental disorders that are officially part of the DSM system. Making a DSM diagnosis consists of selecting those disorders from the classification that best reflects the signs and symptoms that are afflicting the individual being evaluated. Associated with each diagnostic label is a diagnostic code, which is used primarily by institutions and agencies for data collection and billing purposes. These diagnostic codes are derived from the coding system used by all health care professionals in the United States, known as the ICD-9-CM.  Diagnostic Criteria Each disorder included in the DSM includes a set of diagnostic criteria including symptoms that are present and for how long. These criteria called inclusion criteria as well as those symptoms that must not be present called exclusion criteria qualify and individual for a particular diagnosis. Many users of the DSM find these diagnostic criteria useful because they provide a compact description of each disorder. Use of this diagnostic criterion has been shown to increase diagnostic reliability and increase the likelihood that different individuals will assign the same diagnosis). It is important to remember that these criteria are meant to be used as a guideline by an informed clinician.  Descriptive Text The third component of the DSM is the descriptive text that accompanies each disorder. The text of the DSM-IV systematically describes each disorder under the following headings: Diagnostic Features; Subtypes and/or Specifiers; Recording Procedures; Associated Features and Disorders; Specific Culture, Age, and Gender Features; Prevalence; Course; Familial Pattern; and Differential Diagnosis. The DSM uses a multi-axial approach to diagnosing because rarely do other factors in a person’s life not impact their mental health. It assesses five dimensions. The DSM Multi-Axial System Axis I Clinical Syndromes  This is what is thought of as the diagnosis (e.g. depression, schizophrenia, social phobia); Clinical Disorders and ther conditions that may be a focus of clinical attention.  More Examples- Delirium due to a general medical condition; Generalized anxiety disorder; Noncompliance with
  • 15. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 15 treatment; Malingering; Identity problem Axis II Developmental and Personality Disorders  Developmental disorders including autism, mental retardation and disorders which are typically first evident in childhood.  Personality disorders which are clinical syndromes having more long lasting symptoms and encompass the individual’s way of interacting with the world. They include Paranoid, Antisocial and Borderline Personality Disorders. Axis III Physical Conditions which play a role in the development, continuance, or exacerbation of Axis I and II Disorders  Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here; Concussion, medical-induced postural tremor; congestive heart failure Axis IV Severity of Psychosocial Stressors  Events in a person’s life, such as death of a loved one, starting a new job, college, unemployment, and even marriage can impact the disorders listed in Axis I and II. These events are both listed and rated for this axis.  Problems are grouped into: - Primary support group - Social environment - Educational - Occupational - Housing - Economic access to healthcare services - Interaction with the legal system/ crime - Other psychosocial and environmental problems Axis V Highest Level of Functioning  On the final axis, the clinician rates the person’s level of functioning both at the present time and the highest level within the past year. This helps the clinician understand how the above four axes are affecting the person and what type of changes could be expected.  The GARF Scale can be used to indicate an overall judgment of the functioning of a family or other ongoing relationship on a hypothetical continuum ranging from competent, optimal relational functioning to a disrupted, dysfunctional relationship (APA, 2000). Global Assessment of Relational Functioning (GARF) Scale: 1. GARF of 81-100 Overall: The individual is functioning satisfactorily from self- report of participants and from perspective of observers. There is a situationally appropriate, optimistic atmosphere in the family. A wide range of feelings are expressed freely and managed within the family unit. There is a general feeling of warmth, caring, and a sharing of values among all family members. Sexual relations of adult members are satisfactory (APA, 2000). 2. GARF of 61-80 Overall: Functioning of the individual is somewhat unsatisfactory. Over a period of time, many but not all difficulties are resolved without complaints. A range of feelings are expressed but instances of emotional blocking or tension is evident. Warm and caring feelings are present but are marred by family members irritability and frustrations. Sexual activity of adult members may be reduced or problematic (APA, 2000). 3. GARF of 41-60 Overall: Relational unit has occasional times of satisfying and competent functioning together, but clearly the relationship is dysfunctional. Unsatisfying relationships tend to predominate. Pain and ineffective anger or emotional complications interfere with family enjoyment. Although there is somewarmth and support for members, it is usually unequally distributed. Troublesome sexual difficulties between adults are often present (APA, 2000). 4. GARF of 21-40 Overall: Relational unit is seriously dysfunctional; forms and time periods of satisfactory relating are rare. There are infrequent periods of enjoyment of life together; frequent distancing or open hostility reflects conflicts that remain unresolved and painful. Sexual dysfunction among adults is common (APA, 2000). 5. GARF of 1-20 Overall: Relational unit is too dysfunctional to retain continuity of contact or attachment. Despair and cynicism are pervasive; there is little attention to the emotional needs of others; there is no sense of attachment, commitment, or concern about one another’s welfare (APA, 2000). Major Psycho-Diagnostic Features of the DSM – IV-TR________________________________________________ According to the DSM-IV, mental disorders are conceptualized as clinically significant behavioral or psychological syndromes or patterns that occur in a “person” and are associated with “distress” (a painful symptom) or “disability” (impairment in one or more important areas of functioning). In addition, the syndrome or pattern must not be an acceptable response to a particular event (APA, 2000). The DSM system can be difficult to interpret for those with limited clinical expertise or personal familiarity with mental disorders. It is however relatively easy for experienced counselors to learn. Each DSM- IV contains specific diagnostic criteria, the essential features and clinical information associated with the disorder, as well as differential diagnostic considerations. Information concerning diagnostic and associated features, culture, age, gender characteristics, prevalence, incidence, course and complications of the disorder, familial pattern and differential diagnosis are included. Many diagnoses require symptom severity ratings (mild, moderate, severe) and information about the current state of the problem (e.g. partial, or full remission).
  • 16. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 16 The DSM-IV contains fifteen categories of mental disorders: 1. Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence – focuses on developmental disorders and other childhood difficulties. 2. Delirium Dementia, Amnestic and other Cognitive Disorders – this includes Alzheimer’s conditions and Vascular Dementia. 3. Mental Disorders Due to a General Medical Condition – this includes anxiety and mood difficulties as well as personality change due to physical complications. 4. Substance Related Disorders – consist of drug and alcohol abuse and dependence. 5. Schizophrenia and Other Psychotic Disorders – this is a continuum of difficulties that stress lack of contact with reality as well as Delusional Disorders. 6. Mood Disorders and Anxiety Disorders – includes major Depression and Posttraumatic Stress Disorder are featured diagnoses. 7. Somatoform Disorders 8. Factitious Disorders 9. Dissociative Disorders 10. Sexual and Gender Identity Disorders 11. Eating Disorders 12. Sleep Disorders 13. Impulse Control Disorders 14. Adjustment Disorders 15. Personality Disorders Groupings of Personality Disorders Cluster A Is characterized by limited range of emotion in social interactions and form few if any close relationships with others. They are generally suspicious others. 1. Paranoid:  .5% -2.5% of the general population.  10% - 30% reside in residential settings.  2%-10% participate in outpatient mental health settings. 2. Schizoid:  This is uncommon in clinical settings 3. Schizotypal:  3% of the general population Cluster B Characterized by violating the boundaries of others. 1. Antisocial:  3% of males and 1% of females in community samples.  Up to 30% in substance abuse settings. 2. Borderline:  2% of the general population  10% participate in outpatient programs  20% reside in residential settings 3. Histrionic:  2%-3% of the general population  10%-15% participate in both residential and outpatient settings 4. Narcissistic:  1% of the general population  2%-16% of the clinical populations Cluster C Characterized by being socially inhibited, usually feel inadequate and are overly sensitive to criticism. 1. Avoidant:  .5%-1% of the general population  10% of the clinical populations 2. Dependent  unknown 3. Obsessive/compulsive  1% of the general population  3%-10% of the clinical populations Source: DSM-IV-TR for Clinicians: Accurate Diagnosis and Effective Treatment Planning, (2006).
  • 17. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 17 Differential Diagnosis______________________________________________________________________ The key to accurate treatment is for the clinician to come up with the accurate differential diagnosis. There are four steps to take that will ensure accuracy: Step 1: • Is the presenting symptom real? There are two conditions in the DSM –IV –TR that are characterized by conscious feigning:  Malingering is a behavior aimed at the achievement of a clear goal such as insurance compensations, avoiding legal or military responsibilities or obtaining drugs.  Factitious diagnosis is a behavior that lacks a clear external gain Step 2: • Rule out Substance Etiology Virtually all psychiatric presentations that are encountered by clinicians can be caused by substances that act on the central nervous system. Failure to recognize substance etiology is a leading cause of diagnostic errors. The presence of substance use and psychopathology does not establish a cause and effect relationship. Three possible connections must be explored:  Do the psychiatric symptoms result from the direct effects of the substance on the central nervous system?  Is the substance use a consequence of having a primary psychiatric disorder (e.g. using alcohol or drugs to manage the symptoms)?  Are the psychiatric symptoms and the substance using independent? When diagnosing a substance induced disorder, a clinician must determine whether there is a close relationship between the substance use and psychiatric symptoms. The clinician must also consider the likelihood that the particular pattern of substance use can result in the observed psychiatric symptoms. Finally, it should also be considered whether or not there is a better alternative explanation (i.e., non-substance induced) for the clinical picture. Substance withdrawal must also be considered. The DSM-IV-TR criteria for substance induced suggest that psychiatric symptoms be attributed to the substance use if they remit within a month of the cessation of acute intoxication, withdrawal or medication use. There has been significant debate regarding the four week time limit. Step 3: • Rule out a Disorder due to a General Medical Condition. Any psychiatric presentation can be caused by the direct physiological effects of a general medical condition. There are five possible relationships to explore:  Whether the general medical condition causes the psychiatric symptoms through a direct physiological effect on the brain.  Whether the general medical condition causes psychiatric symptoms through a psychological mechanism (e.g., depressive symptoms in response to being diagnosed with cancer – diagnosed as Major Depressive Disorder Or Adjustment Disorder.  Whether the medication taken for a general medical condition causes the psychiatric symptom.  Whether or not the psychiatric symptoms cause or adversely affect the general medical condition  Whether or not the psychiatric symptoms and general medical condition are coincidental. There are two considerations when ruling out medical conditions:  The temporal relationship: Do the psychiatric symptoms begin following the onset of the general medical condition, vary in severity with the severity of the general medical condition and disappear when the general medical conditions resolves?  The Atypical Course is the next consideration to look at: If the psychiatric presentation is atypical in symptom pattern, age at onset or course.
  • 18. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 18 Step 4: • Determine the Specific Primary Disorder(s) A clinician can utilize the decision trees in the DSM-IV along with the diagnostic Criteria Charts. The DSM-IV is not the only psych-diagnostic nomenclature in existence, but it is the most popular. An up-to-date understanding of this diagnostic system and its implications in counseling is imperative for an individual to be effective and ethical in his/her delivery of professional mental health counseling services. Advantages and Disadvantages of utilizing the DSM IV____________________________________________ Assigning a diagnosis to a client remains uncomfortable for many counselors. The disadvantages associated with using the DSM have included the promotion of a mechanistic approach to mental disorder assessment. There is a false impression that the understanding of mental disorders is more advanced than is actually the case. There is an excessive focus on the signs and symptoms of mental disorders to the exclusion of a more in depth understanding of the client’s problems including human development. Conversely, advantages to implementing the DSM include the development of a common language for discussing diagnoses. There has been an increase inattention to behaviors and the facilitation of the overall learning of psychopathology. Seligman (1990) has indicated that knowledge of diagnosis is important for counselors so that they may provide a diagnosis for clients with insurance coverage and inform clients if their counseling will be covered by medical insurance. In addition, the DSM diagnosis assists with accountability, record keeping, treatment planning, communication with other helping professionals and identification of client with issues beyond areas of expertise. Socio-cultural Implications________________________________________________________________ Professional counselors utilizing DSM-IV diagnoses yield sizable power that can be interpreted as oppressive to some groups of people. Psycho-diagnosis therefore is reliant on ethno-cultural and linguistic sensitivity (Malgady, Rogler & Constantino, 1987). Clients of lower socioeconomic class may experience, define and manifest mental disorders differently from middle and upper class clients. The DSM’s lack of focus on the problematic features of a social context may be perpetuating the oppression of certain groups of people (e.g., women). Gender and race of the clinician also have been found to impact an accurate psych- diagnosis (Loring & Powell, 1988). Counselors using the DSM-IV will need to be aware of the implications associated with its use as well as the impact a diagnosis may have on a client’s treatment both within and outside of the counseling process. Religion is often at odds with the existence of mental disorders. Some religions prohibit or discourage psychotherapy. Some religions prohibit or discourage psychiatric medication. Religious ideation is at times prevalent in psychotic delusions.
  • 19. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 19 Part 3: Assessment Factors in Dual Diagnosis “Drug addicts or substance abusers have dual diagnosis: substance addiction or substance dependence, and psychiatric disorder whether it’s depression or anxiety. These patients become drug addicts because they are self-medicating.” “Some of the statistics in the hospital would say that yes, they started as saying they have specific psychiatric disorder but they end up being addicts.” Dr. Noel Reyes Psychiatrist, National Center for Mental Health (In an interview by Flores published at Philippine Star, 2007) Traditional psychiatric treatment has divided patients into distinct categories based on the belief that one type of illness or disorder is primary or more urgent than another. Historically, patients were categorized as having either a mental illness or a substance abuse or dependency problem and received separate treatment for each disorder. The mental health community has now recognized and focused increased attention on the needs and appropriate treatment of patients with dual diagnosis and co-occuring disorders. The complexity of needs, problems, and multiple impairments in patients with co-occuring disorders requires a comprehensive assessment, therapeutic treatment approach and individual case management. Patients with psychiatric illnesses and substance abuse or dependency problems have poor treatment outcomes with high rates of relapse, resulting in high costs in multiple settings. Defining Dual Diagnosis__________________________________________________________________ The term dual diagnosis refers to the presence of at least one psychiatric disorder in addition to a substance abuse or dependency problem. The psychiatric disorder might be a mental illness or a personality disorder. An example of a person with dual diagnosis is an individual with chronic schizophrenia and alcohol abuse. Another example is a patient with heroin dependency and antisocial personality disorder. Considering the number of axis I and axis II diagnoses, a multiple combination is possible. Therefore patients with co-occuring disorders or disorders that occur at the same time represent a heterogenous group. Research studies indicate that about 49% to 60% of patients in treatment settings have co-occuring disorders and are 3-4 times more likely to be hospitalized than those with mental illness alone (Dilonardo et al., 2008; Havassy et al., 2009). Dynamics of Dual Diagnosis ______________________________________________________________ One issue that mental health professionals traditionally deal with is which comes first- the mental illness or the substance abuse problem. Consider the following examples of dual diagnoses: Examples of Dual Diagnoses Axis Diagnosis I Schizophrenia Alcohol Abuse I II Cocaine Abuse Antisocial Personality Disorder I Major Depression Anxiolytic Dependency I II Major Depression Marijuana Abuse Borderline Personality Disorder
  • 20. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 20 From the perspective that mental illness occurred first, many reasons might account for the development of a substance abuse problem. As is true for mental illnesses, heredity, environmental and biologic factors might predispose an individual to problems with substances. Some people might be predisposed to develop both a mental illness and a substance abuse problem. From the idea that substance abuse precedes mental illness, it follows that brain chemistry can be altered- that is, neurotransmitter imbalance or depletion can occur. Chemicals can induce acute and chronic psychiatric problems. Substance-induced psychosis, schizophrenia, depression and mania can occur in vulnerable individuals. Substance abuse can also lead to feelings of guilt, depression, and altered self-esteem. Repeated stimulant use can alter the dopamine system, and alcohol dependence can increase the positive symptoms of schizophrenia (Addington and Addington, 2001; Littrell and Littrell, 2009). Environmental and psychological factors, such as poor social and educational functioning, boredom, dysphoria, unemployment and poverty are contributing factors leading to the risk of substance abuse. Individuals with severe and persistent mental illness such as schizophrenia experience adverse consequences with even a modest use of alcohol and psychoactive drugs (Green et al, 2007).Specific drugs are abused based on market forces and use begins prior to development of psychosis. In the Philippines, it has been noted by the Dangerous Drugs Board that eight million Filipinos are drug users.  Self-medicating with alcohol or drugs can help patients with psychotic symptoms feel better and less anxious; using substance do not result in uncomfortable side effects as compared to antipsychotics; but results in worsening of symptoms after the effects of alcohol or drug have worn-off.  Social acceptance, feeling of autonomy or power, problems and issue are avoided and that a higher degree of self-esteem and control are felt when drink alcohol or use substance. Studies have shown that for individual with severe mental illness, substance use offers an opportunity to socialize, which can be a prime reason for use (Drake et al., 2002).  Individuals with schizophrenia have reported using alcohol, cannabis and cocaine to bdecrease depression, anxiety and side effects of antipsychotic medications (Addington and Addington, 2001).  Individuals with depression sometimes use stimulants to boost their energy so thay can work and care for their families.  Substance abuse issues are often present in the population of individuals with personality disorders. Some traits or behaviors of substance abusers are the same as those with personality disorders. Regardless of which disorder comes first, the existence of a substance problem, mental illness or personality disorder complicates diagnosis and treatment, prolongs rehabilitation, in increase the incidence of relapse, associated with violence, homelessness and in some cases contracting HIV and Hepatitis infection (Drake et al, 2002). The complexity of these patient’s problems requires skills in assessment to be able to apply a holistic and integrated approach for treatment. Dual Diagnosis: Screening and Assessment____________________________________________________ The DSM-IV TR is a standard assessment tool in diagnosing patients with Dual Diagnosis. However, as mentioned in earlier discussion, the DSM-IV TR is not the only method in defining and classifying mental health problems. The nurses’ skills in assessment in conjunction with his professional and personal attributes with good communication techniques play a major role in the process of assessment. Irrespective of the service to which problems are first presented, screening and assessment is fundamental to achieving better diagnostic outcomes. Considerations include; the experience of the assessment, the
  • 21. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 21 environment of the assessment, a high index of suspicion, a robust assessment process that includes a thorough history, and the use of appropriate screening and assessment tools in a multi-disciplinary context. Without rigorous detection, problems will be missed or attributed inappropriately, and may result in the subsequent treatment or care response being inadequate, incorrect, or even neglectful. Nurses who perform screening and assessment must seek to understand the patient’s story and perspective on their illness, and should not exclude their family members or significant others. Although screening and assessment may incorporate standardized tools and involve some medical investigations (blood, urine, and hair analysis), an evaluation of occupational capacity, social or relationship functioning and quality of life are also important in determining the client’s life experience. Assessment is likely to take place over the mid to long term and thus require regular monitoring as well as continual interaction and collaboration between colleagues working in allied services. The use of common protocols and processes is desirable because it avoids the unnecessary repetition of multiple assessments, which patients may find exhausting and may lead to resistance to further assessment. It also helps to establish common understanding of terminology, definitions, approaches, interventions and outcome expectations.
  • 22. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 22 Part 4 Formulation of Assessment-based Care Plan Nursing Diagnosis___________________________________________________________ A nursing diagnosis is the identification of patient’s problems based on conclusions about the dynamics evident in verbalizations and behavior. It is directly related to the content, mood and interaction themes described in the previous discussions. Emergency behaviors (eg.: suicidal or homicidal ideas or attempts, aggression, destructive behaviors, risk of arson or escape) are given priority in establishing no-harm agreements with patients. Suicidal intent should be regularly assessed, whether or not a patient agrees to a no-harm contract (Lynch, et al, 2008). Regardless of format or style of the nursing diagnosis in a particular setting, the diagnosis should be specific and indicate a desired outcome for the patient. The NANDA International diagnosis is the most widely accepted and used nursing diagnoses. It suggests a statement format that has the following three components:  Risk for actual problems  Contributing, causative or etiologic factors  Defining characteristic or behavioral outcome It is typically written as follows:  (Problem) related to;  (Contributing factor) as evidenced by;  (Behavioral outcome Eg.: “Anxiety, moderate, related to marital problems as evidenced by ineffective problem solving.”  Actual or potential problems are identified from the list approved by NANDA International  Contributing or causative factors can include stressors, losses, past experiences, developmental issues, environmental circumstances, relationship issues, and self-perceptions.  Defining characteristics or behavioral outcomes are the very verbal and nonverbal cues that reflect the patient’s actual or potential problems.  These maladaptive behaviors or cues are the focus of the nursing interventions- behaviors that it would be helpful to change.  Being specific when describing the dysfunctional behaviors or cues is useful in providing direction for selecting desirable or adaptive behaviors identified in the patient’s desired outcomes.  It does not include medical diagnosis in any of the three parts of diagnostic statement. Outcome Identification_________________________________________________________ A goal or outcome specifies an adaptive behavior to replace one that is dysfunctional. Expecting patients to change a negative self- image to a positive self-image during a short inpatient stay or outpatient program is unrealistic. A more realistic behavioral goal would be to ask patients to write a list of their strengths, abilities and positive qualities. This goal is achievable and measurable.  Short term goals or outcomes are those achievable in perhaps 4-6 days for hospitalized patients and perhaps somewhat longer for patients in other settings.  Long term goals or outcomes relate to issues that require follow-up counseling after discharge to another type of service within the continuum of care, example; Goal Statement Short-term Identify difficulties with intimate relationships Long-term Practice how to respond to anxiety-provoking dating situations; thus, by increasing awareness of fears, the patient might be better able to address these types of situations.  In establishing goals and outcomes with a patient (collaboration), the nurse must understand the problems the patient wants to address and the goals the patient wants to achieve.  Patient desire and motivation play a major role in attaining outcomes (Atreja et al., 2005). Patient support systems and resources might also facilitate outcome achievement (Mc Bride, 2000).
  • 23. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 23 Planning and Intervention_______________________________________________________ Nursing Care Plans Nursing staff, on units or in programs, often develop standardized care plans with expected outcomes for certain types of patient problems. These care plans might focus on psychiatric diagnoses (eg.: major depression) or more specific problems (eg.: self- mutilation). The initial nursing care plan might be updated at any time but begins with one or two behavior-oriented problems to be addressed immediately (eg.: suicide, aggression, arson, escape, withdrawal or isolation, delusion, hallucinations, impulsive or compulsive acts, suspiciousness, uncooperativeness, or altered though processes). For example:  A patient who has suicidal ideation (problem) would be expected to sign a no-harm agreement (outcome) within 24 hours (time constraint) and to verbalize a plan for dealing with suicidal ideation (outcome) by 3 days of admission (time constraint).  Related nursing interventions would include (1) an agreement with the patient for safety, (2) removal of dangerous objects from the patient and the patient’s room, and (3) assessment for suicidal ideation during every shift. Given the current managed care climate, a goal of standardized care plans is to expedite treatment activities to achieve patient outcomes in a cost-effective manner. Nursing interventions focus particularly on “safety, structure, support and symptom management” (Delaney et al., 2000). However, the nurse must remember that each patient is an individual, even some of the patient’s problems fit into a standardized plan. A patient’s unique problems and needs must not be ignored when formulating the plan of care (Benner, 2000). Historically, psychiatric nursing interventions involve few hands-on activities other than minor treatments, monitoring vital signs and giving medications. However, there is an increasing recognition of the chronic disease that many people who live with mental illness experience because these people tend to die from chronic diseases many years earlier than their nonpsychiatry ill counterparts. Medical conditions are undertreated in the psychiatry settings; Psychiatric nurses must use both interpersonal skills as well as health assessment skills on behalf of their patients. Nevertheless, the focus of psychiatric nursing is often on verbal strategies (as shown in the previous example of recording and MSE with Mrs. Aguilar) that are used to guide patient in exploring and solving problems for themselves and achieving desired outcomes. Psychiatric nurses are primarily facilitators and educators. Solving problems and changing behaviors are never quite easy as they sound. Patients might need help with developing specific and concrete plans for reaching their goals. Progress Notes and Shift Reports The style of charting progress notes (written or electronic) varies in each setting, but the components are basically the same: the patient’s statements and the nurse’s observation, analyses and plans. Charting and shift reports are important ways of communicating with team members to ensure continuity of care. These reports are also ways the short term and long term outcomes. Patients must also be kept informed of their progress towards their goals. The nurse must remember that the entire chart is a legal document subject to review by peer review agencies, quality improvement staff and accreditation bodies (Oermann and Huber, 1999). Progress Note Components Subjective content The patient’s statements about his own thoughts, feelings, behaviors and problems. Objective content The nurse’s observations or measurements, such as the patient’s appearance, nonverbal behavior and vital signs. Analysis or conclusions The nurse’s impressions of what the patient is experiencing or demonstrating in behavioral or descriptive terms (not medical diagnosis); defenses, mood and issues are identified; depressed mood and paranoid ideas can be discussed, but “depression” and “paranoia” are not listed as illnesses.; conclusions about changes (regression or progression) in the patient and medication responses are described. Plans Actions that nurses or other team members can take to intervene with the problems described in the progress note.
  • 24. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 24 Sample Progress Note for Marlene Aguilar Date and Time: 08/26/2013 0500 Subjective content Patient states that she is a little less tired. States she is still unsure what led to the separation and cannot face living alone. Still have thoughts of suicide but no plan: “I still wish I were dead”. Verbalizes that she still does not know what to do about impending divorce and being alone in the future. Said she called her employer to extend her sick leave and called her son and daughter who will visit this evening. Objective content Exhibits blunted, depressed affect, slowed motor activity and speech. Attended one therapeutic group and a craft activity, but only one participated briefly. Napped for only 2 hours this shift. Analysis or conclusions Patient cannot describe her thoughts and feelings, but guilt, helpless ness and hopelessness are evident. Anger is barely evident at this point. Suicidal but lacks energy to plan. Support is available from her adult children. Plans  Approach and seat with patient frequently.  Encourage verbalization of feelings especially anger.  Monitor energy level and suicidal ideation  Continue medication as ordered  Encourage participation in group meetings and activities. Evaluation _________________________________________________________________ Patient Progress The more realistic and measurable are the goals, the greater is the likehood that patients and nurses will have a sense of progress. A major problem arises with evaluating care in psychiatric nursing when too much change is expected too soon. When the patient or nurse becomes aware of a lack of progress towards goals, evaluation should lead to reassessment. Using the nursing process leads to reformulation of the nursing diagnoses and the establishment of more realistic, appropriate outcomes. Even when short term goals are met, patients have other unsolved problems. If the short term goals were related to learning better skills (eg.: communication, problem solving , social skills), then patient can continue to progress after discharge. Evaluating patient progress is important in determining patient referrals to other levels of care and supervision within the continuum of care. The issue of prior nonadherence with medications and treatments needs to be addressed early in the admission. This might affect the type of referrals made for outpatient referral (Julius et al, 2009). In addition to evaluating the progress notes of patients, nurses evaluate the quality of interventions and their professional behaviors. Discharge Summaries Nurses today are more proactive in writing transfer or discharge summaries and discharge instructions that are given to patients. Summaries usually identify outcomes that must still be addressed. The information included in the discharge summary are as follows:  Medications (dosages and time)  Follow-up appointments (with dates and time)  Referrals to other services in the continuum of care It is important to assess the patient’s ability to read and understand the discharge instructions. Process Recordings Process recordings are tools for the nurses to learn about working with patients effectively. It is a way to gain deeper understanding of the communication process (eg.: rehabilitation setting in which communication is impaired by stroke). The use of communication skills via process recordings emphasize as a means of helping patient learn and solve problems. It provides a means of assessing and analyzing communication skills, identifying patient themes and evaluating the effectiveness of the interventions (Festa et al., 2007). Audiotape and videotape recordings are more accurate compared with written reports but
  • 25. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 25 resources cannot always afford for these media. In most settings, written process recordings is utilized which might begin with notes taken during the interview or might be completely assembled by recall afterward. A process recording is a record of encounter with a patient that is verbatim as possible. The recording generally includes the nonverbal behaviors of the nurse and the patient, as well as the verbal interaction. Analysis of content, mood and interaction themes might be included next to each written statement or summarized at the end of the process recording. It may be analyzed by the nurses or shared with a fellow colleague who can provide constructive feedback on problem areas and strategies for improvement (see the sample process recording for Marlene Aguilar in Part 1). Sample Care Plan Name: MARLENE AGUILAR Admission Date: 25 August 2013 DSM-IV-TR Diagnosis: Depressive episode Assessment Areas of Strength: Has family who cares; had good work record; has asked for help; is thinking abstractly Problems: Is unable to get out of bed and care for self; has suicidal thoughts but no plan; exhibits decreased socialization and support; impending annulment Diagnosis  Risk for suicide related to impending annulment and wish to be dead  Anxiety related to anger and fear of living alone, as evidenced by expressing helplessness  Hopelessness related to lowered self-esteem, as evidenced by not caring for self Outcomes Short term goals  Patient will agree to talk with staff when she thinks wanting to be dead  Patient will verbally express anger at husband and situation  Patient will contact friend, employer and children for assistance Long term goals  Patient will state where will she live after discharge  Patient will verbalize confidence in her ability to support self  Patient will describe resources available to her, especially if she becomes suicidal again Planning/ Interventions Nurse-patient relationship  Initiate suicide precaution as a nursing measure; monitor energy level and suicidal ideas; encourage activities of daily living; teach relaxation techniques; offer support as feelings are expressed; reinforce strengths; assist in compiling a list of resources. Psychopharmacology  Fluoxetine 20 mg PO every morning Milieu Management  Encourage patient to stay out of room; request patient attendance at grief and loss, self- esteem, assertiveness, problem-solving and recreational groups. Evaluation Patient will stay with daughter after discharge; patient called employer and request extended sick leave Referral Patient made appointment for outpatient counseling; patient has information on annulment recovery group and a 24-hour crisis and suicide hotline. _____________________________________________________________________________
  • 26. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 26 References: Textbooks: Basic Concepts of Psychiatric- Mental Health Nursing; Author- Louise Rebraca Shives, 6th Edition Keltner’s Psychiatric Nursing; Authors- Norman L. Keltner, Carol E. Bostrom, Teena M. McGuines Psychiatric-Mental Health Nursing, 4th Ed.; Author- Sheila L. Videbeck Journals: WHO-AIMS/ DOH report on mental health system in the Philippines (2006), Manila, Department of Health APA (2000); DSM-TR (4TH ED.); Washington DC, APA Internet Resources http://www.azdhs.gov/bhs/tr_resources/ea/pdf/pm.pdf www.psychpage.com/learning/library/.../mse.htm aitlvideo.uc.edu/aitl/MSE/MSEkm.swf www.psychpage.com/learning/library/.../mse.htm
  • 27. PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING Prepared by CHRISTIAN LUTHER FABIA, R.N., Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 27