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Initial psychiatric assessment

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Initial psychiatric assessment

  1. 1. Initial PsychiatricInitial Psychiatric AssessmentsAssessments Teresa Chahine MSN, PMHNPTeresa Chahine MSN, PMHNP Oakland University, School of NursingOakland University, School of Nursing
  2. 2. Components ofComponents of Mental Health HistoryMental Health History  Patient IdentificationPatient Identification  Chief ComplaintChief Complaint  Associated Symptoms Affecting FunctioningAssociated Symptoms Affecting Functioning  History of Presenting IllnessHistory of Presenting Illness  Past Psychiatric HistoryPast Psychiatric History  Substance Use HistorySubstance Use History  Medical-Surgical HistoryMedical-Surgical History  Social HistorySocial History  Mental Status ExaminationMental Status Examination  Safety AlertsSafety Alerts
  3. 3. Patient IdentificationPatient Identification  NameName  AgeAge  GenderGender  RaceRace  AddressAddress  Emergency ContactEmergency Contact  Guardianship StatusGuardianship Status  Legal HistoryLegal History  Evaluation StatusEvaluation Status  VoluntaryVoluntary  PetitionedPetitioned  Court OrderCourt Order  Modified Court OrderModified Court Order  Insurance CoverageInsurance Coverage  Living SituationLiving Situation  Source of IncomeSource of Income  AllergiesAllergies
  4. 4. Chief ComplaintChief Complaint  What does the client see as the presenting problem.What does the client see as the presenting problem.  Critical Characteristics:Critical Characteristics:  OnsetOnset  PrecipitantsPrecipitants  Aggravating factors/StressorsAggravating factors/Stressors  DurationDuration  SeveritySeverity  Associated symptomsAssociated symptoms  What relieves symptoms/coping strategiesWhat relieves symptoms/coping strategies  Patient’s understanding of problemPatient’s understanding of problem
  5. 5. Associated SymptomsAssociated Symptoms  Self Harm*Self Harm*  Aggression/AgitationAggression/Agitation  Violence towards othersViolence towards others  Impulsivity*Impulsivity*  Hopelessness*Hopelessness*  HelplessnessHelplessness  Activities of Daily LivingActivities of Daily Living  Social CircumstancesSocial Circumstances  Work PerformanceWork Performance  Anxiety*Anxiety*  Panic Attacks*Panic Attacks*  AnhedoniaAnhedonia  PsychosisPsychosis  Emotional StateEmotional State  Coping StrategiesCoping Strategies  AppetiteAppetite  Sleep DisturbanceSleep Disturbance  Global Insomnia*Global Insomnia* * These symptoms are directly correlated to suicide risk factors.
  6. 6. Level of FunctioningLevel of Functioning Activities of Daily LivingActivities of Daily Living  Ability to bathe, etcAbility to bathe, etc  Adhere to treatmentAdhere to treatment  Attend to houseworkAttend to housework  Maintain EmploymentMaintain Employment  HobbiesHobbies  SocializationSocialization AppearanceAppearance  Physical CharacteristicsPhysical Characteristics  DressDress  GroomingGrooming  HygieneHygiene  Eye ContactEye Contact  Facial ExpressionFacial Expression
  7. 7. History of Presenting IllnessHistory of Presenting Illness Past Psychiatric HxPast Psychiatric Hx  Current TreatmentCurrent Treatment  Current MedicationsCurrent Medications  Onset of illnessOnset of illness  HospitalizationsHospitalizations  History of AdherenceHistory of Adherence  History of Trauma:History of Trauma:  Child AbuseChild Abuse  RapeRape  Domestic ViolenceDomestic Violence  Family Psychiatric HistoryFamily Psychiatric History Past Addiction HxPast Addiction Hx  Current UseCurrent Use  Current TreatmentCurrent Treatment  History of WithdrawalsHistory of Withdrawals  DTsDTs  SeizuresSeizures  Onset of UseOnset of Use  Periods of SobrietyPeriods of Sobriety  History of TreatmentHistory of Treatment  Family Addiction HistoryFamily Addiction History
  8. 8. Medical-Surgical HistoryMedical-Surgical History  Serious or Chronic IllnessesSerious or Chronic Illnesses  Current MedicationsCurrent Medications  Recent HospitalizationsRecent Hospitalizations  SurgeriesSurgeries  InjuriesInjuries  AllergiesAllergies
  9. 9. Social HistorySocial History  Living SituationLiving Situation  RelationshipsRelationships  Marital StatusMarital Status  Current RelationshipCurrent Relationship  Longest RelationshipLongest Relationship  Family StructureFamily Structure  Support SystemSupport System  EducationalEducational  Occupation/Work HistoryOccupation/Work History  Financial SupportFinancial Support  Ethnic or Spiritual Issues (if apply)Ethnic or Spiritual Issues (if apply)
  10. 10. Mental Status ExamMental Status Exam  LethalityLethality  Self HarmSelf Harm  Assaultive BehaviorAssaultive Behavior  Destruction to PropertyDestruction to Property  Mood & AffectMood & Affect  Speech PatternSpeech Pattern  Thought PatternThought Pattern  OrientationOrientation  Thought ContentThought Content  MemoryMemory  HallucinationsHallucinations  DelusionsDelusions  InsightInsight  JudgmentJudgment Please give specific examples and quote client’s statements.
  11. 11. Safety AlertsSafety Alerts  Medical conditions requiringMedical conditions requiring immediateimmediate treatment.treatment.  Active alcohol or benzodiazapine intoxicationActive alcohol or benzodiazapine intoxication or withdrawal.or withdrawal.  Actively psychotic with commandActively psychotic with command hallucinations.hallucinations.  Actively suicidal or homicidal with intent.Actively suicidal or homicidal with intent.  Dependent children suspected of beingDependent children suspected of being neglected or abused by client.neglected or abused by client.
  12. 12. Special Considerations:Special Considerations: Pre-teen and TeensPre-teen and Teens Ages 8-17Ages 8-17  Suicidal AssessmentSuicidal Assessment  Substance Abuse/DependenceSubstance Abuse/Dependence  Attention-Deficit and DisruptiveAttention-Deficit and Disruptive Behavior DisordersBehavior Disorders  Tic DisordersTic Disorders  Communication DisordersCommunication Disorders  Learning/Developmental DisordersLearning/Developmental Disorders  Elimination DisordersElimination Disorders
  13. 13. ImpressionImpression  Summary of data which supports theSummary of data which supports the documented diagnoses.documented diagnoses.  Axis I through VAxis I through V  Severity of illness and intensity of care.Severity of illness and intensity of care.  Plan of carePlan of care  Nursing interventions and outcomes.Nursing interventions and outcomes.  Disposition (referrals)Disposition (referrals)
  14. 14. Multiaxial SystemMultiaxial System  Axis IAxis I Clinical DisordersClinical Disorders --Other conditions that may be aOther conditions that may be a focus of clinical attention.focus of clinical attention.  Axis IIAxis II Personality DisordersPersonality Disorders Mental RetardationMental Retardation  Axis IIIAxis III General Medical ConditionsGeneral Medical Conditions  Axis IVAxis IV Psychosocial and EnvironmentalPsychosocial and Environmental ProblemsProblems  Axis VAxis V Global Assessment of FunctioningGlobal Assessment of Functioning
  15. 15. Axis IV: Psychosocial andAxis IV: Psychosocial and Environmental ProblemsEnvironmental Problems  Primary Support GroupPrimary Support Group  Social EnvironmentSocial Environment  EducationEducation  OccupationalOccupational  HousingHousing  EconomicEconomic  Access to Health CareAccess to Health Care  Interaction with legal/criminal systemInteraction with legal/criminal system  Other psychosocial/environmental problemsOther psychosocial/environmental problems
  16. 16. GGlobal Assessment of Functioninglobal Assessment of Functioning (GAF)(GAF)  100-91 life’s problems never seem to get out of hand  90-81 good functioning in all areas, no more than everyday issues  80-71 transient and expectable reactions to psycho- social stressors  70-61 mild symptoms  60-51 moderate symptoms  50-41 Serious symptoms  40-31 unable to work, major impairment in several areas  30-21 Behavior is considerably influenced by delusions or hallucinations OR serious impairment in communication or judgment  20-11 danger of hurting self or others without clear expectations of death.  10-1 Persistent danger of severely hurting self or
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