Psychiatric Mental Health Nursing: Assessment

• Psychiatric mental health nursing involves general assessment considerations.
• Assessment in psychiatric mental health is referred to as a psychosocial assessment.
• The psychosocial assessment serves as the basis for developing a care plan.
• It is a clinical baseline to evaluate the effectiveness of treatment and interventions.
• According to the American Nurses Association (2000), it also measures client progress.

Purpose of Assessment

• To construct a picture of the client's current mental state, mental capacity, and behavioral function.

Factors Influencing Assessment

• Client participation and feedback
• Client health status
• Client's previous experiences and misconceptions about healthcare
• Client's ability to understand
• Nurses' attitude and approach

Interview Techniques

• An interview involves a conversation between the interviewer and interviewee, where questions are used to obtain information.
• Interviews take place in an open area to avoid patient feeling closed in or trapped.
• Meet the client in the waiting area and direct them to a chair, beginning once both seated comfortably at eye level.

How to Conduct the Interview

Environment (A)

• Comfortable, quiet, and safe for both nurse and patient
• Avoid isolated locations if the client is unknown to the nurse or has a history of threatening behavior

Input from family and friends (B)

• If family or friends accompany the patient, the nurse should obtain their perceptions of the client's behavior and emotional state.

Question Phrasing

• Use open-ended and direct questions.
• Maintain a non-judgmental tone and language.
• The nurse should aim to gather information without judgment, which is not part of a phychosocial assessment.
• Being open, clear, and direct eases the client's worries about the topic.
• Examining one's own beliefs helps in the process.
• Nurses' beliefs differing strongly should be discussed with colleagues.
• Personal beliefs must not interfere with the patient relationship or the assessment process.

Initial Patient Assessment

• Demographic data include full name, sex, age, date of birth, address, marital status, family members' names, and ages.
• Admission data includes the date and time of admission and the type of admission (voluntary or committed).
• The reason for admission includes current problems perceived by the patient, stressors, coping difficulties, developmental issues, “emergency behaviors” (suicidal/homicidal ideas/attempts, aggression,destructive behaviors, and risk of escape), and family history.
• Previous psychiatric history includes dates, inpatient/outpatient treatments, reasons, effectiveness, current medications, compliance, and current medical problems.
• Assess drug and alcohol use/abuse, including amount, frequency, duration of past/present use of legal/illegal substances, date, and time of last use.
• Disturbances in the patterns of daily living, culture/spirituality, and support systems are reviewed.
• Assess sleep patterns, intake, elimination, sexual activity, work, leisure, self-care, and hygiene.
• Culture/spirituality encompasses ethnicity, beliefs, practices, and religious preferences.
• Support systems involve the amount of contact, the nature/quality of relationships, and the availability of support.

Mental Status Examination

• Assess general appearance, behaviors during the interview, orientation, memory, thought clarity and thought processes reflected in speech
• General appearance considers the type, condition, and appropriateness of clothing, grooming, cleanliness, physical condition, and posture.
• Behaviors during the interview include expression of anger (covert, overt, verbal, or physical), degree of cooperation, resistance or evasiveness, and social skills (positive/unpleasant habits, shyness, withdrawal)
• Assess the amount/type of motor activity including psychomotor retardation, agitation, restlessness, tics, tremors, and hypervigilance or lack of activity.
• Speech patterns that need to be noted are, amount, rate, volume, pressure, mutism, slurring, or stuttering.
• Orientation assesses awareness of time, place, and person, including the level of consciousness.
• Memory covers recent and remote recall, amnesia, blackouts, and confabulation.
• Assess thought clarity, coherence, confusion, and vagueness
• Thought processes reflected in speech include blocking, circumstantiality, loose association, flight of ideas, preservation, tangential ideas, ambivalence, neologisms or "word salad".
• Thought content includes helplessness, hopelessness, worthlessness, guilt, suicidal ideas/plans, suspiciousness, phobias, obsessions, compulsions, preoccupations, antisocial attitudes, blaming others, poverty of content or denial.
• Delusions can be of reference, influence, persecution, grandeur, religious, or somatic origin. Hallucinations can be visual, auditory or other such as tactile.
• Intellectual functioning uses language and knowledge, abstract vs. concrete thinking, or calculations.
• Affect/mood includes anxiety level, elevated or depressed mood, labile, blunted or flat affect, or inappropriate affect, and feelings that might be expressed.
• Assess insight and judgment of client.
• Evaluate degree of awareness of problems and their causes
• Assess soundness of solving problems and the way decisions are taken

Therapeutic Relationship

• A therapeutic relationship is established between a healthcare professional and a client.
• The goal is to help the client solve their problems.
• Factors for enhancement is the nurses's responsibility to develop.

Components of the therapeutic relationship

• Trust: Confidence in the nurse, integrity, reliability, and consistency.
• Congruence: Matching words and actions.
• Empathy: Understanding and communicating the meaning and feelings of the client.
• Acceptance: Avoiding judgments but setting boundaries for behavior clearly and firmly.
• Genuine interest: Being aware of one's strengths and weaknesses and showing honesty
• Positive Regard: Appreciating the client as a unique and worthwhile human being.
• Self-awareness and Self-analysis: Understanding one's own beliefs and values is a therapeutic tool that offers quality nursing care. The use of self requires self – awareness.

Therapeutic Use of Self

• Introduced by Hildegard Peplau in 1952, it promotes patient growth through communication skills to help patients learn to solve problems; Nurses use themselves in this process

Trust Building

• Key trusting behaviors include caring, candor, objectivity, respect, understanding, and consistency.

Self-Awareness

• Self awareness: Understanding Values attitudes, motivations, prejudices, strengths and limitations.
• Values are abstract standards that give a sense of right and wrong.
• The Values Clarification Process gains insight into the self, done through 3 steps of choosing, prizing and acting.

Increase self-awareness by:

• Listening to the self and to others
• Practicing self-disclosure and altruism
• Clarifying one's values
• Exploring one's feelings

Johari Window

• It is a tool for interconnected components in Self-awareness: Psychological, Physical, Environmental and Philosophical factors that creates a word portrait of a person.
• A change in any one quadrant affects all the quadrants.
• The smaller the first quadrant, the poorer the communication will be.
• Interpersonal learning aims to increase the scope of the first quadrant to increase self awareness.

Carper's Four Patterns of Knowing (1978)

• Empirical knowing: derived from the science of nursing
• Personal knowing: derived from life experiences
• Ethical knowing: derived from the moral knowledge of nursing
• Aesthetic knowing: derived from the art of nursing
• These patterns help nurses observe and understand every client interaction.

Therapeutic Communication

• Interaction focuses on client's needs for effective information exchange,
• It is a face-to-face process that focuses on physical and emotional well-being. Interpersonal communication is needed to promote effective exchange of information

Factors Influencing Communication

• Attitude
• Sociocultural factors
• Past experiences
• Knowledge of subject matter
• Ability to relate to others
• Interpersonal perceptions
• Environmental factors

Types of Communication

• Verbal
• Non-verbal (vocal cues, gestures, physical appearance, distance/spatial territory, position/posture, touch, and facial expression)

Classification of Communication

• Social communication, small talk occurs daily
• Therapeutic communication which helps clients to communicate perceptions, fears, anxieties, frustrations, expectations, and dependency

Characteristics of Therapeutic Communication (GUCHA)

• Goal oriented
• Understanding
• Concreteness
• Honest
• Acceptance

Therapeutic Communication Techniques

• Broad openings: Encourages selecting topics for discussion
• Clarification: Putting vague ideas into words to enhance the understanding
• Reflection: Validation of the understanding
• Restating: Indicates and validates what has been said
• Giving information, sharing how medication works
• Focusing topic of importance.
• Consensual validation: Verifying overall meaning of a message
• Offer self: Communicate interest to understand clients

Additional Therapeutic responses

• Acknowledging: Being nonjudgemental
• Presenting reality: Helping a patient differentiate the actual from unreal
• Summarizing discussion to introduce care planning

Aspects of communication to avoid

• Failure to listen
• Conflicting verbal and nonverbal messages
• Judgemental attitude or overloading
• Information overload and lack of focus
• False reassurance or giving advice
• Disagreement or becoming uncomfortable with subject

When Interacting with Difficult Clients

• Avoid taking client statements personally,validate the client's emotions
• Speak slowly and maintain a soft voice
• Maintain distance and ask simple questions

Focus of Therapeutic Relationship

• Enhance self worth
• Improve coping strategies
• Reinforce self-worth and self concept

Types of Relationships

• Social relationships: initiated for friendship and accomplishing tasks. Roles may shift and outcomes are rarely assessed
• Intimate relationships: Involves 2 emotionally interlocked people including sharing goals, but no place in the nurse-client environment
• Therapeutic relationships: the focus is on the client’s feelings and needs with the nurse’s communication skills

Comparison of Relationships

• Social Interactions are intimate while therapeutic is personal.
• Social focuses on doing favors while therapeutic promotes resources of the patient.
• Identifying the needs is performed by the client in a therapeutic enviroinment.
• The resource is the intervention from a professional

Phases of the Nurse-Client (N-C) Relationship

1. Pre-interaction and Orientation
   • The nurse explores feelings and fantasies about working with psychiatric patients.
   • The nurse meets the patient and identifies the reason for seeking help.
   • A nursing assessment is formed.
   • Establish understandings and open communication
   • Establish trust
   • Formulating a contract
     • Elements of the N-P (nurse-patient) contract include names, meeting times/location, roles/responsibilities, expectations, purpose, condition for termination, and confidentiality.
2. Working
   • Explore relevant stressors, promote insight, and master anxieties.
   • N helps patients master anxieties, increase independence and self-responsibility
3. Termination
   • Discuss feelings of the treatment
   • Learn progress, the progress given, and evaluate mutually

Factors showing when treatment will terminate

• Relief from the problem, improved social interaction, improved effective defense by the patient after planned support.

Important tips to remember (TEACH)

• T: Trust and Rapport
• E: Environment
• A: Assess strengths and weaknesses
• C: Contract
• H: Help communicate

Summary Acronym

• Working Phase (PROVIDE): Promote self-concept, Realistic goal setting, Organize support, Verbalize feelings, Implement action, Develop coping, Evaluate

Summary Acronym

• Termination Phase (PRIDE): Promote self-care, Recognize anxiety, Increase independence, Demonstrate stability, Environmental support

Nursing Diagnosis-North American Nursing Diagnosis Association (NANDA)

• Identifies patient problems based on dynamics of verbalizations
• Has three components to statement: actual problems, problems contributed to, and characteristics
• Should be relevant to problem and potential issues.
• Statements include problem + potential and related factors
• No medical diagnostics in statement

Outcome Identification

• The goals should be adaptable
• This specifies to replace dysfunctional behavior
• Mutual ID with the patient will make it clear
• Set as short- or long-term goals
• This is an essential step in the therapeutic process

Planning

• After diagnosis made, determine priorities by the nurse
• Involves the patient family and health team
• Outline the plan to achieve
• Identify what requires attention

Implementation

• Initiation of plan from the nursing process
• During phase, continue assessment of the patient
• Outcome achieved by intervention
• 2 types, dependent and independent

Types

• Dependent: derives action from the psychiatrist
• Independent: derives action from nursing diagnosis

Evaluation

• Determine whether expected outcome is met by analysis and quality of patients' progress, including looking back at previous phases of the nursing cycle.
• Feedback mechanism used to indicate progress and problems solved

Documentation

• POR: Problem oriented Record
• Uses subjective, objective assessment and implementations
• DAR has similar components like process recordings

Process Recording

• Records interactions that uses tool to analyize what will be discovered