NURSING PROCESS IN

PSYCHIATRIC NURSING
N341
Objectives
 Describe components of a psychiatric
assessment including mental status
examination
 Be able to perform a mental status

examination appropriately
Assessment
 Establish rapport and understanding of current
problem
 Accomplished through observation, interview,

and examinations
 Multiple sources used
 Includes
 Current problem
 Psychosocial assessment
 Physical exam
 Mental Status Exam
Mental Status Examination
 Evaluation of patient’s current status
 Objective, nonjudgmental

 Influenced by education and sociocultural

factors
 Assess communication

 Content
 Process
 Monitor own feelings
Mental Status Exam Categories
 General description
 Appearance, speech, motor activity, interaction

 Emotional state
 Mood, affect

 Experiences
 Perceptions

 Thinking
 Thought content and process

 Sensorium and Cognition

 LOC, memory, concentration, calculation, information,

intelligence, judgment, insight

Appearance
 General description of patient
 Appears age
 Dress
 Appropriate for situation and weather
 Cleanliness
 Posture
 General state of health
Speech
 Rate
 Volume

 Amount
 hyperverbal
 pauctiy
 mute
 Characteristics
 Stuttering, slurring, pressured
Motor Activity
 Level of activity
 Gait

 Unusual activity or gestures

 Tics, tremors, grimaces
 Repetitive movements
 Walking on toes
Interaction
 Subjective
 Facial expressions

 Eye contact, body language, & tone

 Positive interaction
 Open, pleasant, cooperative
 Negative interaction
 Hostile, uncooperative, irritable, guarded, defensive,
suspicious
Mood
 Self-report of prevailing emotion
 “How do you feel today?”
Affect
 Apparent emotional tone
 Range
 Stability
 Appropriateness/congruence
Perception
 Hallucinations
 Auditory
 Visual
 Tactile
 Gustatory
 Olfactory
 Illusions
 Depersonalizion/derealization
Thought Content
 What patient is thinking
 Common topic or theme
 Suicidal or homicidal thoughts
 Obsessions
 Phobias
 Delusions
 grandiosity, paranoia, somatic, religious
 Neologisms
 Thought insertion/broadcasting
 Ideas of reference
Thought Process
 How patient is thinking
 Organized, goal-directed
 Circumstantial thinking
 Tangential
 Loose associations
 Flight of ideas
 Word salad
 Perseveration
Sensorium & Cognition
 Level of Consciousness
 Alert, drowsy, lethargic, stuporous
 Orientation
 Person, place, time, and situation
Memory
 Remote
 Recent

 Immediate

 Confabulation
Concentration and Calculation
 Count from 1-20
 Count back from 100 by 7’s

 Simple math
Information and Intelligence
 Use caution in judgment
 Last grade completed in school

 General knowledge

 Vocabulary

 Literacy

 Interpretation of proverbs
Judgment
 Constructive and adaptive decisions
 Hypothetical situations
Insight
 Understanding of one’s problems or illness
 Acceptance or denial of problems
Watch an example
Rating Scales
 Measure extent of pt’s problems
 Help with diagnosis

 Track progress over time

 Document effectiveness of treatment

 http://deploymentpsych.org/system/files/member_resource/Insomnia%20Severity%20Index%20-ISI.pdf
Nursing Diagnosis
 Statement of actual or potential problems or
health promotion diagnoses
 Based on behavioral response to stress

 Example: Ineffective coping R/T recent death of

husband and lack of internal resources AEB

insomnia, frequent crying, inability to function at
work, passive suicidal thoughts
Goals
 Focus on relieving symptoms and improving
functioning
 Mutually identified with patient

 Observable behavior with time-frame

Implementation
 Coordination of care
 Health teaching and health promotion

 Milieu therapy

 Pharmacological and biological therapies

Evaluation
 Improved symptoms, functioning, and
wellbeing
 Clinical outcomes
 Function
 Patient Satisfaction