MENTAL HEALTH ASSESSMENT
The psychiatric interview is the most important tool in psychiatry. It is used to understand the patient’s problems, elicit signs and symptoms, etiology, and complications to make appropriate diagnosis, initiate treatment and predict out come.
What to assess and how to make a diagnosis.
- Taking a history.
- Psychiatric assessment.
- Do physical examination.
- Request for investigation e.g biological i.e blood ,urine, x-ray, psychological investigation, social investigation e.g home visit and environmental investigation.
Conditions during consultation.
- Time should be enough.
- There should be privacy.
- Consultation room should be tidy. Untidy room influences negative
- No other interferences for example answering telephone calls influence patient to be
- Health worker:.Decoration of the health worker for example finger, eye brows, lips, head.
ESTABLISHING THERAPEUTIC RELATIONSHIP.
The quality of the information that you got depend on the confidentiality and trustworthiness that the patient sees in you. Decoration of health worker. Patient will not personal and diagnostically important information with somebody they do not trust. Rapport is basic and understanding and trusting relationship between the patient and the nurse.
ELEMENTS OF RAPPORT.
- Respect for the patient despite his appearance or socioeconomic status. This is sense by the patient.
- Compassion for his suffering and distress.
- Genuiness, good-will and an attitude that the patient will experience as non-judgmental, interested and concern. If the patient is accompanied by the relative or friend and he desire them to be around this should be allowed however if what you are going to ask may need confidentiality they may need to leave. Be culturally sensible for example sexual history; African dress cord.
MUST
- Explain to the patient the reasons for the interview.
- Reassure the patient about the need of the interview.
General principles of the interview include:
- Active observation and awareness of behavior (gait ,physical appearance ,facial expression )
- Assessment and evaluation is a two way process ( note that the patient is also assessing you, show attention ,listen and with care)
- Acceptance of patient’s behavior (all behavior has meaning )
- A void arguments with the patient (be assertive without arguing)
- Do not assume, understand the patient(make sure you understand what the patient says or feels)
- Stress on feelings (e.g. if a patient cries should be given an opportunity to unburden themselves ,emotionally charged areas should be explored )
- Focus on interpersonal relationship (sense of love )
- Avoid being judgmental
- Show empathy
- Try to tolerate silence
The psychiatric assessments include history taking, mental status examination and investigation. History is from patient, family, relative or friend who has been close to the patient .
Psychiatric history include
Identifying data:
- Name
- Age
- Tribe
- Occupation
- Religion
- Next of kin
- Marital status
- Highest level of education.
Referral system
- Source of referral (health worker, family member ,police )
- Reasons for referral (indicate the main reason for referral )
Chief complaints and duration of symptoms
History of present illness
- The patient’s problems are explored and emotional illness of the patient in the past.
- Should be diagnostic in nature
- Possible different diagnosis
- Possible stressors /causes
- Any complications
Past psychiatric and mental history
- The physical and emotional illness of the past
- Type of investigations and their results(HIV test inclusive )
- Diagnosis
- Treatment received
- Outcome of such treatment
Family history (parents )
- For each family member, note the relationship with the patient.
- Their current health condition
- Find out if the parent or relative is directly dependent on the patient and how she feels about it
- Presence of mental illness among the nuclear or extend family
Personal history
- Pregnancy ,birth and early development up to 6 years (more important in children than adults )
- Six years of puberty (school ,peer group activities )
- Adolescence to 19 years (sexual history ,interests )
Occupational history
- Nature of work
- Job satisfaction, problem at work place.
Marital status
- Age at which the person got married
- Spouse’s occupation
- Spouse and children’s health
- Marital relationship
Forensic history
- Has the patient ever had problems with the law?
Mental status examination
Background
MSE is a systematic appraisal of the appearance, behaviour, mental functioning and overall demeanor of a person.
Appearance: A person’s appearance can provide useful clues into their quality of self-care, lifestyle and daily living skills for example distinctive features, clothing, grooming, hygiene
Behaviour: As well as noting what a person is actually doing during the examination, attention should also be paid to behaviours typically described as non-verbal communication. These can reveal much about a person’s emotional state and attitude: facial expression, body language and gestures, posture, eye contact, response to the assessment itself, rapport and social engagement, level of arousal (e.g. calm, agitated), anxious or aggressive behaviour, psychomotor activity and movement (e.g. hyperactivity, hypoactivity) , unusual features (e.g. tremors, or slowed, repetitive, or involuntary movements)
Affect: Range (e.g. restricted, blunted, flat, expansive), appropriateness (e.g. appropriate, inappropriate, incongruous)
Mood: Happiness (eg, ecstatic, elevated, lowered, depressed)
Irritability (e.g. explosive, irritable, calm)
Speech
Speech can be a particularly revealing feature of a person’s presentation and should be described behaviourally as well as considering its content (see also section on Thoughts). Unusual speech is sometimes associated with mood and anxiety problems, schizophrenia, and organic pathology.
- Speech rate (e.g. rapid, pressured, reduced tempo)
- Volume (e.g. loud, normal, soft)
- Tonality (e.g. monotonous, tremulous)
- Quantity (e.g. minimal, voluble)
- Ease of conversation
Cognition
This refers to a person’s current capacity to process information and is important because it is often sensitive (though in young people usually secondary) to mental health problems.
Level of consciousness (e.g. alert, drowsy, intoxicated, stuporose)
Orientation to reality (often expressed in regard to time/place/person – e.g. awareness of the time/day/date, where they are, ability to provide personal details)
Memory functioning (including immediate or short-term memory, and memory for recent and remote information or events)
Thoughts
A person’s thinking is generally evaluated according to their thought content or nature, and thought form or process.
Content: find out if there are Delusions (rigidly held false beliefs not consistent with the person’s background), overvalued ideas (unreasonable belief, e.g. a person with anorexia believing they are overweight),preoccupations, depressive thoughts, self-harm, suicidal, aggressive or homicidal ideation, obsessions (preoccupying and repetitive thoughts about a feared or catastrophic outcome, often indicated by associated compulsive behaviour)
Perception
Illusions:
The person perceives things as different to usual, but accepts that they are not real, or that things are perceived differently by others
Hallucinations:
Probably the most widely known form of perceptual disturbance. Hallucinations are indistinguishable by the sufferer from reality. Can affect all sensory modalities, although auditory hallucinations are the most common
In children it is common to experience self-talk or commentary as an internal “voice” Command hallucinations (voices telling the person to do something) should be investigated . Important to note the degree of fear and/or distress associated with the hallucinations
Insight:
Acknowledgement of a possible mental health problem. Understanding of possible treatment options and ability to comply with these
Judgment:
Refers to a person’s problem-solving ability in a more general sense
Can be evaluated by exploring recent decision-making or by posing a practical dilemma (e.g. what should you do if you see smoke coming out of a house?)
Physical examinations
- Vital Observation
- Systemic examination
Carry out investigations if need be
Develop the nursing care plan
- Group the findings into objective and subjective data
- Formulate the Nursing Diagnosis (patients needs)
- Identify the goals, methods and resources to be used
- Implement the nursing care plan
- Evaluate the care plan