Psychiatric Nursing Lecture Note for Third Year Extension Nursing Students Prepared by Tesfa D. (B.Sc.) July, 2003/2011.

Unit-Two Assessment of psychiatric patient

 Assessment

of psychiatric patient is mostly takes place through psychiatric interview techniques

Medical

diagnosis is made based on detailed history, physical examination and using x ray, CT. lab and other tests.

 In

psychiatry these technological development doses not work. did not contribute and nothing to diagnosis of the functional psychosis and other neurotic conditions.

They

 Psychiatric

diagnosis is not the theoretically based, treatment non specific, criteria based and no concrete confirmatory test. single most important tool to arrive in diagnosis on psychiatry is very good psychiatric interview.

The

way of eliciting signs and symptoms. asses psychotic thinking. Psychotic behavior, suicidal and homicidal thoughts or plans, hospitalization.

To

 To

gain knowledge about the patient and the nature of problem.

Patients

psychological make up, psychosocial development, coping strategies.

 To

give a chance to the patient to express his emotion, establishes a proper working relationship or rapport with the patient.

very good interview has a very good psychotherapeutic effect on the patient.

 If

the examiner has the qualities of genuineness, the ability to understand patients problem and warm and friendly manner, s/he can develop a trusting relationship with the patient. assess significant social, religious and cultural influences on the patients life.

To

 Room: Free

from interruption

Privacy Comfort

and safety to the patient and nurse.

The first encounter with the patient: Observe

the patient from waiting area. who is with the

Identify

patient.

 Observe

the appearance and behavior of the patient on waiting area.

Welcome

him/her by name and by hand shakes.

 Observe

how the patient respond and tell him your name, also welcome the escorts.

Seating position of the patient: Not

opposite to the interviewer, rather at the side of the desk.

Chair

should not be lower than the interviewer.

Question techniques: Question can be injected when the patient gives appropriate leads.
No No

leading question.

interpretative comments at the beginning of the interview.

Note taking and recording: Record

some verbatim statements

only.
If

the patient objects to note taking it is best to discontinue and to listen.

 Reassurance

that the notes are

confidential.
Do

not forget excessive not taking during the interview inhibits free communication, inhibit observation of non verbal massages of the patient.

Time: Not If

more than one hour

the patient is a psychotic and agitated patient you can interrupt you interview and continue later.

Open ended questions;

Begin

with broad open ended questions the patient to speak as much as possible

Allow

e.g. Can you tell me about the troubles that bring you today?
Then

allow the patient to speak as much as possible

e.g. What other troubles do you have?

 If

the patient stops, ask him/her, tell me more about this? early part of the interview is the most open ended in which the patient talks and you listen.

The

Closed ended question  It is used to ask specific information. e.g. age, address, name and others
 Use

closed ended questions in eliciting information about certain symptoms. e.g. Hallucination, suicidal ideation.

 We

use them in assessing factors such as frequency, severity and the duration of the symptoms. not use closed ended questions at the beginning of the interview. Because it does not allow the patient to have the options.

 Do

Reflection;
The

nurse repeats to the patient in supportive manner something that the patient has said. is an emphatic response.

It

 The To

purpose of reflection is;

assure the examiner that he/she has correctly understand what the patient trying to say. let the patient know that his/her message is understood.

To

Facilitations;
To

point out to a patient something that the examiner thinks he is not paying attention to, missing, or some way denying. must be done on skilful way so that the patient is not forced to become hostile defensive.

It

Positive enforcement  The patient sometimes might have difficulty to express his problem clearly. When the patient struggled with a particular topic and is then unable to express clearly, then examiner signals his/her approval by using positive reinforcement. E.g. Good, that helps me a lot to understand you.

Summation:
 Periodically

during the interview the examiner can take a moment and briefly summarize what the patient said.

 It

occurs both the patient and examiner that the information the examiner has heard is the same with what the patient is talking.

Explanation;
 The

nurse explains the treatment plan to the patient in easily understandable language.

Psychiatric assessment includes:Psychiatric history II. A physical examination III.Psychiatric examination/Mental status examination IV. Further investigations V. Formulation of the case
I.

A)

Identification

 Name,

age, marital status, sex, occupation, religion, visits come from, referred from, come with.

B) Chief complaints
 Exactly

why the patient come to the hospital? Preferably in the patients own words; if the information does not come from the patient note that who supplied it.

E.g. Do not say insomnia, say sleeplessness.

Common psychiatric symptoms/compliants



Anxiety: A state of feeling uncertainty experienced in response to an object or situation. Stress: A state of extreme difficulty, pressure or strain with negative effects on physical and emotional health and well-being. Withdrawal: A state of habitual quiet and seeming un concerned with other people a focus on ones own thoughts.

Depression: A mood state characterized by a feeling of sadness, dejection (self dislike), despair, discouragement, or hopelessness. Suicide: The act of killing oneself (self distracting behavior). Neurosis: A condition in which mal adaptive behaviors serves as a protection against a source of unconscious anxiety.

Personality disorder: A non psychotic illness characterized by maladaptive behavior that the person uses to fulfill his or her needs and bring satisfaction to him or her self. As a result of the inability to relate to the environment, the persons actions conflicts socially. Hysteria (conversion disorder): The loss or impairment of some motor or sensory function for which there is no organic cause. Formerly known as hysteria or hysterical neurosis.

Mental retardation: A disorder characterized by sub average intellectual functioning associated with or resulting in, the inability or impairment of the ability to think abstractly, adapt to new situations, learn new information, solve problem, or profit from experience. Dementia: A defuse brain dysfunction characterized by a gradual, progressive, and chronic deterioration of intellectual function. Judgment, orientation, memory, affect or emotional stability, cognition, and attention all are affected.

Trauma: A severe physical injury to the body from an external source; or a severe psychological shock. Alcohol dependent: A person who can not break the habit of drinking alcoholic drinks too much, especially one whose health is damaged because of excessive alcohol intake. Schizophrenia: A serious mental disorder characterized by impaired communication with loss of contact with reality and deterioration from a previous level of functioning in work, social relationships, or self care.

Paranoid disorder: A psychotic state characterized by moderately, or seriously, impaired reality testing, affect and sociability, accompanied by persecutory, grandiose, erotic or jealous content delusions. Manic-depression: A mood disorder involving both mania and depressive episode.

Illusion: A false interpretation or perception of a real environmental stimulus that may involve any of the senses. Hallucinations: Sensory perceptions that occur in the absence of an actual external stimulus. They may be auditory, visual, olfactory, gustatory or tactile. Delusion: False belief not true to fact ordinarily accepted by other members of the persons culture

C) History of present illness Once the examiner has elicited the patient main problems he should summarize them by saying, So far, as I understand it you have been suffering from this and this, is will go to each of this, before that do you have anything to add?

 For

each problem elicited the interviewer should seek the following information: The

time of onset:- the time when the problem began.

 Mode


of onset:- gradual, sudden

That the problem is related to any particular events or factors.

e.g. loss, physical illness, rape and other.

evelopment over time:- changes in the intensity and frequency The help given:- traditional like holy water (how long, may times, any improvement).

 Impact

of the problem:-

An

adverse effect on day to day functioning of the patient family and close friends.

Adverse

effect on his mood, his ability to do his job, level of job satisfaction and his efficiency.

 An

adverse effect on his ability to cope with his day to day activity, on his ability to pursue and enjoy his usual hobbies, enjoyment and social activities.

Any

change on the sexuality of relationship with his wife and immediate family member.

D. Family history
 Do

patient parents alive? If not ask about age and cause of death. What is the reaction of the patient to the death?

 How

many brother and sister/ Are all alive?

 How

is the relationship of the patient with his parents, brothers and sisters?

 Are

they supportive towards him? Was there any major disagreement? id the parent encourage him to become independent or try to delaying this.

 Who

had sought psychiatric help in the family and their diagnosis if known? Psychiatric hospitalization if any.

 What

treatment modalities were administered? out comes of the treatment

 The

 Suicidal  Any

behavior.

history of psychiatric illness on the family. history of physical illness of the family. the parent has separated, the patient should be asked how he responded to this.

 Any

 If

id it cause any particular problem? background of the

 Educational

parent.
 Parental  Parental

violence.

excessive drinking criminal behavior.

E. Personal history Early life and development

When and where the patient born? Any problems surrounding his birth?

id s/he pass the usual milestone on time? Were there any difficulties during his development? Neurotic symptoms in childhood Antisocial behavior Current life situation

Schooling the patient went to school and how he felt about first separation form his mother? How did he get with his peers? How did he progress academically and socially? How did he perceive his teacher? How did he compare himself with other children? Were there any problems with discipline?
When

there any refusal/ Did he experience any leavening difficulties or problems in making friends? How well did he perform in national examination? Delinquent tendency Higher education or training.
Was

Sexuality Sexual inadequacy, sexual deviant practices. Have you made love? How has it worked? Have there been any difficulties? Does the masturbate? If so, how often? What he thinks about it? A female patient
 When

her period began? How regular her periods have been?

Incase of married patient Time couple had known each other Adequacy of sexual relationship Extra marital relationship Was he planned to have children? Were there any difficulties with pregnancy and birth? How do you get on together? Did you plan to have more children?

F. Past medical history  Details of any previous major physical illness.  The diagnosis treatment, out come, duration, present physical health, weight loss, loss of appetite. G. Past psychiatric history  Was there any particular trigger?  What was the exact nature of the illness?


How long it lasted?

o o

What was the treatment? Was there hospitalization?

o

How long it lasted?

How well functioning between the episodes of mental illness? H. History of substance abuse Alcohol abuse: quantity, quality, frequency Chat use: quantity, frequency, poly drug abuse with chat like alcohol, hashish.
o

I. Personality before the illness/Premorbid personality/ Social relations Activities and interests Mood Character Standards, moral, religious, social, economic etc Energy and initiative Reaction to stress

Paranoid personality
How

do you get on with other people? Do you find you can trust people? Do you think people like you generally? Are you treated fairly? Are you self concise?

Schizoid personality Do you have many friends? Can you mix easily? Do you prefer alone or with company? Would you describe yourself as shy?

Anti social personality Have you been in much trouble with police? Do you have impulses to hurt people? Do you dislike being told what to do? Histrionic personality Are you sometimes over emotional? Do you like to be the center of attention? Do you tend to relay on other people?

Obsessive personality Do you always try to follow asset of routine? Do you prefer things to be very neat and tidy? Are you always punctual? Do you ever tend to check things more than once or twice?

J. Negative and positive statement

No

history of heating voices, no history of self neglect, no history of talking alone or laughing lone.

 The

physical examination should be comprehensive and should be carried out within a day of admission. attention should be given to the central nervous system. and negative findings should be recorded and a brief summary of abnormalities found should be given.

Special

Positive

 General

behavior, appearance, word behavior since admission, attitude towards hospital staff etc.

 Talk

(form of talk), much or little, spontaneous, answers to questions etc.

 Mood  Form

of thought; Does the patient experience blocking pressure or poverty in thinking?

of thought Delusions and misinterpretations Hallucinations Obsessional phenomena Orientation to time place and persons. Memory
Content

 Attention

and concentration  General information  Apparent intelligence  Insight and judgement  Staff attitude.

1. General appearance
 Appearance:-

grooming, hygiene, consciousness, eye contact, posture, cooperative or not.

Depressed patient: dull color dress. Manic patient:- Bright color, clashing color, dress may be untidy with buttons undone or done up incorrectly. Dress may be stained, worn torn or it may also be inadequate for the weather.

Self neglect:- Can occur in depression, schizophrenic, and dementia.

Men

may appear unshaven, the face has not been washed and the hair might uncombed or combed carelessly.
may wear, no make up or they may apply their make up carelessly.

Women

Unusual

combination of clothing:- schizophrenic patient. Wearing jacket and shirt or cot back wards. May have additional items of clothing, scarf tied around the forehead to indicate royality.

Unusual

accessories:Schizophrenic patient.

Sometimes pack their pockets with their belonging or carry a large holders of personal possessions or papers or manuscripts.

Finger nails are long and dirty

2. Motor activity

Gait:- unusually slow, unusually fast, unusual character of gait. Abnormal motor activity:- a quick repeated movement of muscle, tic, tardive dyskinesia, stereptype (monotonous).

3. Speech activity:Speed:- unusually fast or slow or normal. Volume:- loud, slow, normal. Quantity:- too little, too much or normal. Tone:- low pitched, high pitched or normal. Non social:- whispering, muttering neologism, word salad.

. Emotional state I) Mood:- is sustained internal emotional state of a person which colors his/her perception of the outside world. Can be depressed irritable, labile, anxious, elated, normal. e.g. Mania & depression are disorder of mood II) Affect:- is externally observable expression of present emotional state. It is what the examiner is observing during the interview. Can be constricted, flat, appropriate, blunted.

. Though process I. Formal thought disorder Concrete ideas (by asking concrete object) and Abstract ideas (by asking proverbs) II. Stream of though (continuity of thought) Flight of ideas (fast speech) Poverty of thought (devoid of thought) e.g. negative symptom of schizophrenia.

Loosening of associations not logical. Word salad (irrelevant words with no connection at all). Circumstantialitys:- disturbance in goal directedness of thinking. Tangentially:- talking much without getting the point. Neologism:- a new word or expression un known by only family.

III. Content of thought

Delusion:- False beliefs not strongly correlated by logical ideas Obsessions:- An irrational, intrusive ideas but they know that they are the product of their own mind Compulsion:- reduce the anxiety of obsession by performing the idea. Phobia:- specific, irrational fear.

. Perception:- are sensory experiences. Hallucination:- false perception of non existing object. (auditory, tactile, visual olfactory etc) Illusion:- false perception of real existing objects (mis perception.

. Cognition Orientation+:- time, place and person First lost:- Time place person First regain:- person place time Memory:- immediate, recent, remote Recent:- past few days to few months Remote:- details of life (remote past) Judgment:- ability to make decision with the situation e.g. ask what will you do if fire is set in theatre while watching movie.

Insight:- knowledge by the patient whether s/he thinks s/he is ill and need treatment or not. Full insight:- they know they are sick and need treatment Partial insight:- they say I think I am sick but I dont need treatment. Lack of insight:- they say I am not sick and I do not need treatment.

Further

investigations may be indicated ,including:

Physical investigations as indicated Psychological testing Psychiatric social worker's report

 Discuss

a range of potential diagnosis, giving evidence for and against the various possibilities. and record a provisional diagnosis, an estimate of prognosis, a problem list, and plans for further investigation and treatment.

Make

The End!!!