The Nursing Process: Assessment of Psychiatric Nursing

INTRODUCTION The nursing process is five-step problem-solving approach that serves as an organizational frame work for the practice of nursing. It sets the practice of nursing in motion and serves as a monitor of quality nursing care.

ASSESSMENT The assessment phase of the nursing process includes the collection of data about the person, family, or group by the methods of observation, examination and interviewing. Two types of data are collected: objective and subjective. Objective data include information obtained verbally from the patient, as well as the result of inspection, palpation, percussions, and auscultation during an examination. Subjective data are obtained as the patient, family members, or significant others provide information spontaneously,

The psychiatric-mental health nurse utilizes the nursing assessment tools:

to obtain factual information observe appearance and behavior evaluate the patients mental or cognitive status.

APPEARANCE General appearance includes: physical characteristics, apparent age, peculiarity of dress, cleanliness, and use of cosmetic.

A person general appearance, including facial expressions, is a manner of nonverbal communication in which emotions, feelings, and mood are related. For example, depressed people 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. Manic patients may dress in bizarre or overly colorful outfits, wear heavy layers of cosmetics, and several pieces of jewelry.

BEHAVIOR, ATTITUDE, AND NORMAL COPING PATTERNS: The interviewer assesses patients actions or behavior by considering the following factors:
1.

Do they exhibit strange, threatening, or violent behavior? Are they making an effort to control their emotions? Is there evidence of any unusual mannerisms or motor activity, such as grimacing, tremors, tics, impaired gait, psychomotor retardation, agitation? Do they pace excessively? Do they appear friendly, embarrassed, evasive, fearful, resentful, angry, negativistic, or impulsive? Their attitude toward the interviewer or helping persons can facilitate or impair the assessment process. Is behavior overactive or underactive? Is it purposeful, disorganized, or stereotyped? Are reactions fairly consistent?

2.

3.

4.

PERSONALITY STYLE AND COMMUNICATION ABILITY The manner in which the patient talks enables us to appreciate difficulties with his thought processes. It is desirable to obtain a verbatim sample of the stream of speech to illustrate psychopathologic disturbances (Small, 1980, p. 8).

Factors to be considered while one is assessing patients ability to communicate and interact socially include the following:
1.

Do they speak coherently? Does the flow of speech seem natural or logical, or is it illogical, vague, and loosely organized? Do they enunciate clearly? Is the rate of speech slow, retarded, or rapid? Do they fail to speak at all or respond only when questioned? Do patient whisper or speak softly, or do they speak loudly or shout? Is there a delay in answer or responses, or do patients break off their conversation in the middle of a sentence and refuse to talk further? Do they repeat certain words and phrases over and over? Do they make up new words that have no meaning to others? Is their language obscene? Does their conversation jump from one topic to another? Do they stutter, lisp, or regress in their speech? Do they exhibit any unusual personality traits or characteristics that may interfere with their ability to socialize with others or adapt to hospitalization? -For example, do they associate freely with other or do they consider themselves loners? Do they appear aggressive or domineering during the interview? -Do they feel that people like them or reject them? How do they spend their personal time?

2.

3. 4.

5. 6. 7. 8. 9. 10.

The following terminologies are generally used to describe impaired communication observed during the assessment process:
1. 2. 3. 4. 5. 6. 7.

BLOCKING CIRCUMSTANTIALITY FLIGHTOF IDEAS PERSEVERATION VERBIGERATION NEOLOGISM MUTISM

BLOCKING This impairment is a sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external or environmental reason. Blocking may be due to preoccupation, delusional thoughts, or hallucinations; for example, while talking to the nurse, a patient stated, My favorite restaurant is Chi-Chis. I like it because the atmosphere is so nice and the food is . . . Most often found in schizophrenics during audio hallucinations.

CIRCUMSTANTIALITY In this pattern of speech the person gives much unnecessary details that delays meeting a goal or stating a point. For example, hen asked to state his occupation, a patient gave a very description of the type of work he did. Commonly found in manic disorder and some organic mental disorders.

FLIGHT OF IDEAS This impairment is characterized by over productivity of talk and verbal skipping from one idea to another. The ideas are fragmentary, although talk is continuous. Connections between the part of speech often are determined by change of associations; for example: I like the color blue. Do you ever feel blue? Feelings can change from the day to day. The days are getting longer. Most commonly observed in manic disorders.

PERSEVERATION Perseveration is the persistent, repetitive expression of a single idea in response to various questions. Found in some organic mental disorders and catatonia. VERBIGERATION This term describes meaningless repetition of incoherent words or sentences. Observed in certain psychotic reactions and mental disorders. NEOLOGISM A neologism is a new word or combination of several words coined or self-invented by a person and not readily understood by others; for examples: His phenologs are in the dryer. Found in certain schizophrenic disorders.

MUTISM This impairment is refusal to speak even though the person may give indications or being aware of the environment. Mutism may occur from conscious or unconscious reason. Observed in catatonic schizophrenic disorders, profound depressive disorders, and stupors of organic or psychogenic origin. Other terminology such as loose association, echolalia, and clang association is described in the chapter discussing schizophrenic disorders.

EMOTIONAL STATE OR AFFECT: Affect is defined as the outward manifestation of a persons feelings, tones, or mood. Affects and emotion are commonly used interchangeably (American psychiatric association, 1980, p. 3). The relationship between mood and the content of thought is of particular significance. There may be a wide divergence between what the patient says or does on the one hand and his emotional state as expressed objectively in his face or attitudes. (Small 1980, p. 10).

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CONTENT OF THOUGHT The American psychiatric association defines thought disorder as a disturbance of speech, communication, or content of thought, such as delusions, ideas of reference. . . . A thought disorder can be caused by a functional emotional disorder or an organic condition (1980, p. 131). Small (1980) and Rowe (1989) describe those thought contents more commonly exhibited during the psychiatric examination:
1. 2. 3. 4. 5.

Delusions Hallucinations Depersonalization Obsessions Compulsions.

DELUSION: A delusion is a fixed false belief not true to fact and not ordinary accepted by other members of the persons culture. It cannot be corrected by an appeal to the reason of the person experiencing it. Delusions occur in various types of psychotic disorders, such as organic mental disorder and schizophrenic disorder, and in some affective disorders.

TYPES OF DELUSIONS
Delusion of reference or persecution

DESCRIPTION
One believes that he or she is the object of environmental attention or is being singled out for harassment. The police are watching my every move. Theyre out to get me. The person believes his or her feelings, thoughts, impulses, or actions are controlled by an external source. A spaceman sends me to do.

Delusions of alien control

Nihilistic delusions The person denies the reality or existence of self, part of the self, or some external object. I have no head. Delusion of self-deprecation The individual feels unworthy, ugly, or sinful. I dont deserve to live. Im so unworthy of your love. Delusion of grandeur A person experiences exaggerated ideas of her or his importance or identify. I am Napoleon! Somatic delusions The person entertains false beliefs pertaining to body image or body function. The person actually believes that she or he has cancer, leprosy, or some other terminal illness.

HALLUCINATIONS Hallucinations are sensory perceptions that occur in the absence of an actual external stimulus. They may be auditory, visual, olfactory, gustatory, or tactile in nature.

Hallucinations occur in substance-use disorders, schizophrenia, and manic disorders.

EXAMPLES TYPES OF HALLUCINATIONS Auditory hallucinations

EXAMPLES

Asie tells you that he hears voices frequently while he sits quietly in his long chair. He states, The voices tell me when to eat, dress, and go to bed each night! Ninety-years-old EK describes seeing spiders and snakes on the ceiling of his room late one evening as you make rounds. AJ, a 65-year-old psychotic patient, states that she smells rotten garbage in her bedroom, although there is no evidence of any foulsmelling material. MY, a young patient with organic brain syndrome complains of a constant metallic taste in her mouth. NX, a middle-aged woman undergoing symptoms of alcohol withdrawal and delirium tremens, complains of feeling worms crawling all over (her) body.

Visual hallucinations Olfactory hallucinations

Gustatory (taste) hallucination Tactile hallucinations

DEPERSONALIZATION: Depersonalization is described as a feeling of unreality or strangeness concerning self, the environment, or both: For example, patients have described out-of-body sensations in which they view themselves from a few feet overhead. These people may feel they are going crazy. Cause of depersonalization includes prolonged stress and psychological fatigue, as well as substance abuse. This feeling has been described in schizophrenia, bipolar disorders, and depersonalization disorders.

OBSESSIONS Obsessions are insistent thoughts, recognized as arising from the self, usually regarded by the patient as absurd and relatively meaningless, yet they persist despites his endeavors to rid himself of them (Small, 1980,p. 13). Person who experience obsessions generally described their thoughts as thoughts I cant get rid of or I cant stop thinking of things . . . they keep going on in mu mind over and over again. Obsessions are typically seen in obsessivecompulsive disorders.

COMPULSIONS An inconsistent, repetitive, intrusive and unwanted urge to perform an act contrary to ones ordinary wishes or standards (American psychiatric association, 1980, p. 21). If one does not engage in the repetitive act due to an inner need or drive, one generally experiences feelings of tension and anxiety. Compulsions are frequently seen in obsessive-compulsive disorders.

ORIENTATION: During the assessment, patients are asked questions regarding their ability to grasp the significance of their environment, an existing situation, or the clearness of conscious processes. In other words, are they oriented to person, place, time and events. Do they know who they are, where they are, or what the date is? Are they aware of the past and current events? Levels of orientation and consciousness are subdivided as follows: confusion, clouding of consciousness, stupor, delirium, dream state, and coma.

LEVELS OF ORIENTATION AMD CONSCIOUSNESS

LEVEL Confusion Clouding of consciousness Stupor Delirium or acute brain syndrome Dream state DESCRIPTION Disorientation to person, place or time characterized by bewilderment and complexity. Disturbance in perception or thought that is slight to moderate in degree, usually owing to physical or chemical factors producing functional impairment of the cerebrum. A state in which the person does not react to or is unaware of the surrounding. The person maybe motionless and mute but conscious. Confusion accompanied by altered or fluctuating consciousness. Disturbance in emotion, thought, and perception is moderate to severe. Usually associated with infections, toxic states, head trauma, and so forth. Disturbed, clouded, or confused consciousness in which the person may not be aware to surroundings. Visual or auditory hallucinations may occur. May last several minutes to a few days Loss of consciousness.

Coma

MEMORY Memory, or the ability to recall past experiences, is divided into recent and long-term. Recent memory is the ability to recall events in the immediate past and up to two weeks previously. Long-term memory is the ability to recall remote past experience such as the date and place of birth, names of schools attended, occupational history and chronological data relating to previous illness. Small (1980) states that memory defects maybe because of lack of attention, difficulty with retention, difficulty with recall, or any combination of these factors. Loss of recent memory maybe seen in patients which chronic organic brain dysfunction. Three disorders of memory are: (1) Hypermnesia or an abnormally pronounced memory (2) Amnesia or loss of memory (3) Paramnesia or falsification of memory

INTELLECTUAL ABILITY The persons ability to use facts comprehensively is an indication of intellectual ability. During the assessment the person may be asked general information such as: (1) name the last three presidents (2) to calculate simple arithmetical problems (3) to correctly estimate and form opinions concerning objective matters (Small, 1980, p. 16). The person maybe ask a question such as What would you do if you found a wallet in front of your house? The examiner is able to evaluate reasoning ability and judgments by the response given. Abstract and concrete thinking abilities are evaluated by responses to proverbs such as an eye for an eye and a tooth for a tooth.

INSIGHT REGARDING ILLNESS OR CONDITION Does the person consider him/her well or ill? Does the patient understand what is happening? Is the illness treating to the patients? Insight is defined as self-understanding, or the extent of the one understands of the origin, nature, and behavior. Patients insight into their illness or condition range from poor to good, depending on the degree of

NEUROVEGETATIVE CHANGES Does the patients exhibit change in psychophysiologic functions suck as sleep patterns, eating patterns, energy levels, sexual functioning, or vowel functioning? Depressed persons usually complain of insomnia or hypersomnia, loss of appetite or increased appetite, loss of energy, decreased libido, and constipation, which are all sign of neurovegetative changes. Persons who are diagnosed as psychotic may neglect their nutritional intake, appear fatigue, sleep excessively, and ignore elimination habits (sometimes to the point of developing a fecal impaction.)

RECORDING OF ASSESSMENTS Information obtained during the assessment process is relayed to the members of the health care team in the form of the summary of the history and physical examination, a summary of the social history, a summary of the psychological testing, and multidisciplinary progress notes. Nurse can provide invaluable pertinent information if they follow the criteria of a good recording. Such information is significant to the members of the interdisciplinary team, who use these note as an aid in planning treatment and disposition of patients. Thorough charting shows progress, lack of progress, or regression on the part of the patient. The detail of the patients conduct, appearance and attitude are significant. Increased skill in observation and recording will result in more consist charting. Charting is also important in research because it is an accurate record of the symptoms, behavior, treatment, and reactions of the patient. Charting is recognized by legal authorities, who frequently use the notes for testimony in court.

The basic criteria for charting psychiatric nursing progress notes should be:
1.

Objective: the nurse records what the patient says and does by stating facts and quoting the patients conversation. Descriptive: the nurse describes the patients appearance, behavior and conversation as seen and heard. Complete: a record as of examinations, treatments, medications, therapies, nursing interventions, and the patients reaction to each should be made ob the patients chart. Samples of their patients writing or drawing should be preserved. Legible: psychiatric nursing notes should be written legibly, with the use of acceptable abbreviations only, and no erasures. Correct grammar and spelling are important, and complete sentences should be used. Dated: It is very important to note the time of entry. For the example, MS has been quiet and withdrawn all days; however, later in the evening she becomes agitated. The nurse needs to states the tome at which MSs behavior changed, as well as described any pertinent situation that might be identified as the cause of her behavioral change. Logical: Presented in logical sequence. Signed: by the person making the entry.

2.

3.

4.

5.

6. 7.

EXAMPLE OF NURSING PROGRESS NOTES Various forms of documentation are utilized to record nursing progress notes, including SOAP (subjective data, objective data, Assessment data, and plan of care) Progress notes should reflect the effectiveness of treatment plans. Multidisciplinary progress notes have become more prevalent as they depict a chronological picture of the patients response to various therapeutic interventions.

An example of DAP nursing notes utilizing the multidisciplinary progress note format :
Date And Time Problem Number Multidisciplinary Progress Notes

07 06 - 09 9:00am

#1

D: RK was eating breakfast at 8:00am when she began to perspire profusely and stated, I dont know whats wrong with me, but I feel jittery inside. I feel like something terrible is going to happen. When ask to describe her feelings, RK replied,I cant. I just have an awful feeling inside. Affect blunted. Pallor noted. Tearful during interaction. Minimal eye contact. Voice tremulous. P = 120, R = 38, BP = 130/80. No sign of acute physical distress noted at this time. A: Expressing fear of the unknown and inability to maintain control of her emotions. Recognized she is experiencing symptoms of anxiety but unable to utilize effective coping skills. P: Encourage verbalization of feelings when able to interact/communicate needs. Explore presence of positive coping skills. Administer prescribed anti anxiety agent. Monitors response to medication.

Note: problem #1 refers to *ineffective individual Coping *NANDA approved nursing diagnosis.

Ineffective Individual Coping Ineffective Individual Coping

REFERENCES: AMERICAN Psychiatric Association. (1980). A psychiatric glossary (5th ed.). Washington DC: American Psychiatric Press. Barry, P.D (1989). Psychosocial nursing assessment and Intervention (2nd ed.). Philadelphia: J.B. Lippincott. Kolb, L. (1977). Modern Clinical Psychiatry. Philadelphia: W.B Saunders. Rowe, C.J. (1989). An outline of Psychiatry (9th ed.) Dubuque, 1A: Brown Publishing.

Examples of Nursing Diagnosis: -Body image disturbance -Potential for violence, or self harm -Social Isolation -Ineffective Family Coping -Impaired Grooming -Self Care Deficit -Knowledge Deficit -Sensory Deficit -Spiritual Deficit -Sleep Pattern Disturbance

I.

Related Learning Clinical Activities Activities A. Assess the following areas of your assigned patient:
1. Appearance 2. Behavior 3. Attitude 4. Ability to communicate 5. Emotional state or affect 6. Content of thought 7. Orientation 8. Memory 9. Intellectual Ability 10. Insight regarding illness B. Summarize the data obtained to give an informative report about the patients mental health status. C. Chart pertinent information using descriptive, noninterpretive data.

II.

Independent Activities A. Use the following nonverbal behavior assessment guide while communicating with fellow students or friends: 1. State any significant nonverbal behavior, such as finger tapping, tics, or poor eye contact. 2. State the possible reason for or meaning of the behavior, such as fear, anxiety, boredom, or impatience. B. List nursing interventions for the identified behavior.

III. Case Study Behavioral Assessment A. WJ, 45-year-old patient admitted for emergency surgery for a bleeding ulcer, is referred to the psychiatric unit for a consultation because of symptoms of depression of anxiety. This married man has four children, two of whom are still living at home while attending college. He runs his own business and often works 10 to 12 hours each day. He had one previous hospitalization two years ago, when he had surgery for cancer of the colon. WJ is alert and oriented in ICU but gets little sleep at night. While awake, he watches the nurses carefully and is very pleasant when he converses with them. When he calls for a nurse and one does not respond immediately, WJ begins to shout until someone arrives. His requests are often minor and he could have waited. The staff is not certain how much WJ knows about his latest surgery, but his response is Im glad it wasnt cancer. Maybe this happened to slow me down. He usually terminates such discussions by stating that he has to rest and suggests that the attending staff care for other patients who are sicker than he is. B. From the information given: 1. List the possible stressors before and during hospitalization. 2. Describe WJ present coping mechanisms. 3. While providing nursing care for WJ, identify stressors that the staff may experience. 4. Write informative nursing progress notes regarding WJs behavior.

THE FOLSTEIN MINI-MENTAL STATE

MAXIMUM

Score
5 5

Score
( ) 1. ( ( ( ( ( ( ( ( (

Question

Orientation Registration

3 Attention and Calculation Recall Language 5 3 2 1 3 1 1

Ask the patient to name the year, season, date, day, and month. (1point each) ) 2. Ask the patient to give her/his whereabouts: state, country, town, street, floor.(1 point each) ) 3. Ask the patient to repeat three unrelated objects that you name. Repeat them and continue to repeat them until all three are learned .(1 point each) ) 4. Ask the patient to subtract 7 from 100, stopping after five subtractions, or to spell the word world backwards. .(1 point for each correct calculation or letter) ) 5. Ask the patient to repeat the three objects previously named .(1 point each) ) 6. Display a wrist watch and ask the patient to name it. Repeat this for a pencil .(1 point each) ) 7. Ask the patient to repeat this phrase: No ifs, ands, or buts! .(1 point) ) 8. Have the patient follow a three-point command such as, Take a paper in your night hand, fold it in half, and put it on the floor. .(1 point each) ) 9. On a blank piece of paper write, Close your eyes! ask the patient to read it and do what it says. .(1 point) ) 10. Ask the patient to write a sentence on a blank piece of paper. It must be written spontaneously. Score correctly if it contains a subject and a verb and is sensible (correct grammar and punctuation are not necessary)(1 point) ) 11. Ask the patient to copy a design you have drawn on a piece of paper (two intersecting pentagons with sides about one inch) .(1 point)