Assessment of mental health status.pptx

this ppt covers the how to assess the mental health status of the psychiatry patient

1. ASSESSMENT OF MENTAL HEALTH STATUS Mrs.B.Kavitha M.Sc (N), Professor HOD- Department of Psychiatry, Aswini College of Nursing, Thrissur

2. Syllabus: Assessment Of Mental Health Status -5 hr -History taking -Mental status examination -Mini mental status examination -Neurological examination: review -Investigations: related blood chemistry, EEG, CT & MRI -Psychological tests Role and responsibilities of nurse

3. Nursing Process (NP) is defined as a systematic, continuous and dynamic method of providing care to clients. It comprises series of sequential phases built upon the preceding step. Each phase logically leads to the next. Yura and Walsh, 1978

4. NURSING ASSESSMENT Assessment involves the collection, organization and analysis of information about the patient’s health. In psychiatric mental health nursing, this process is often referred to as a psychosocial assessment

5. EFFECTIVE INTERVIEW SKILL

6. HISTORY COLLECTION It is the record of the Patient‘s life

7. DEFINITION The psychiatry history is the record of the patient’s life; it allows a psychiatrist to understand who the patient is ,where the patient has come from ,and where the patient is likely to go in the future. It allows to understand who the patient is where the patient has come from where the patient is likely to go in the future.

8. PURPOSE To describe adaptive and maladaptive behavior. To formulate priorities. To identify problems. To predict probable responses to potential interventions. To analyze the client’s perceptions. Helps to develop nursing care plan.

9. BASIC PRINCIPLES OF HISTORY TAKING Introduce yourself Explain the purpose and approx how long it will take Ask Open Ended Questions Allow the patient to Explain Things In his/her Own Words Encourage the patient to Elaborate and explain Avoid Interrupting Guide the Interview As Necessary Avoid Asking “Why?” Questions Listen and Observe For Cues You might need an informant

10. I. P ATIENT IDENTIFICATION DATA: Name Age Sex Marital Status Occupation Educational status Religion Address Informant

11. Chief complaints According to the patient: (In patient’s own words) According to the relatives :(In informants own words) Name of the informant, Relationship with patient, degree of concern regarding the patient and reliability of the information(Relevant or not/ adequate or not)

12. II. History of presenting illness When the patient was well the last time should be noted Time of onset - Acute (within a few hours), - Sub acute (within a few days), Gradual (within a few weeks) with Duration – days, weeks or months

13. II. History of presenting illness Presenting complaints should be explained Course – continuous/episodic Intensity / same / increasing or decreasing Precipitating factors – yes/no (if yes explain) History of current episode (explain in detail regarding the presenting complaints)

14. II. History of presenting illness Any associated disturbances – includes present medical problems (E.g. Disturbance in sleep, appetite, IPR & social functioning, occupation etc). Any history that is related to the current episode should be recorded

15. III. PAST PSYCHIATRIC HISTORY: Number of episode with onset and course Complete or incomplete remission Duration of each episode Treatment details and its side effects if any Treatment outcomes Details if any precipitating factors if present

16. IV. PAST MEDICAL HISTORY AND SURGICAL HISTORY V. SOCIO ECONOMIC BACKGROUND

17. VI. FAMILY HISTORY: Family genogram (tree) – 3 generations include only grandparents. Type of family : Joint/Nuclear/extended Consanguinity :Present/Absent Family Health history: History of mental illness/history of Suicide/ drug overdose/ Any personality problems/ Epilepsy etc (give details)

18. VII. PERSONAL HISTORY: Infancy: Mother ante-natal period – supervised/ unsupervised/ eventful/ uneventful Birth: full term/post term/normal Normal/ forceps/cesarean Post natal problems: any problem for the patient- child breath and cried at birth, any neonatal infections Any problems for the mother: maternal infections, exposure to radiation etc. Breast feeding: given up to which month Milestones developments: normal/ delayed Childhood health and assessment : Excessive temper tantrums, H/o nail biting, bed wetting, sleep walking, stammering , night mares, thumb sucking, head banging, morbid fears or phobias Adolescence : Running away, delinquency, smoking, substance abuse and overweight

19. EDUCATIONAL HISTORY : Age of beginning and finishing formal School Performance in the School and academic achievements Relationship with peers and teachers (Specifically look for learning disability and attention deficit) Other achievements and games, hobbies, abilities Look for conduct disorders E.g. Truancy, stealing- Any failures and reason for giving up the education

20. OCCUPATIONAL HISTORY Age of joining job Relationship with superiors, subordinates & colleagues Present income, Job satisfaction and ambitions Appropriative ness of job to his educational and family backgrounds Any changes in the job – if any give details Reasons for changing jobs Frequent absenteeism

21. MENSTRUAL HISTORY: The age at menarche Length of cycle and any specific complaints SEXUAL HISTORY: Source and extent of knowledge about sex, any exposures (Don’t ask unless you are instructed to do so)

22. MARITAL STATUS: Name, Age Education and occupation of spouse Duration of marriage Love/ Arranged marriage Children: Present/Absent If present: No. of children and quality of relationship with the children Number of marriages Interpersonal relationship Any other problems specify

23. VIII. PRE MORBID PERSONALITY: Interpersonal relationships with the family members, friends, coworkers, superiors etc. Hobbies and interest: Mood: Optimistic/ pessimistic Stable Prone to anxiety Cheerful/ Dependent Attitude towards the work and responsibility Decision making Acceptance of responsibility Flexibility Moral, and Religious :adherence/ Not adherence Use of Alcohol/Tobacco Any others (Specify)

24. IX. HEALTH PATTERNS: Hygiene: Maintaining hygiene or not Eating habits: Rest, relaxation and sleeping habits Elimination- Bowel and bladder habits YOUTUBE ID: Psychiatric Interviews for Teaching: Psychosis By university of nottingam

25. MENTAL STATUS EXAMINATION

26. MENTAL STATUS EXAMINATION (MSE) Mental status examination includes the observation of facts as well as the elicitating of information by questioning the patient. In excited or uncommunicative patient a complete examination may not be possible for time being. However a complete examination should be done when the first opportunity arises. Mental status is the total expression of a person’s emotional responses, mood, cognitive function, and personality

27. COMPONENTS

28. I. General appearance and behavior (GAAB) Level of consciousness: conscious/ unconscious/ drowsy. Body built: Endomorphic/Ectomorphic/ Mesomorphic Facial expression (E.g. Anxiety, pleasure, confidence, blunted, pleasant) Dressing and grooming – well dressed/ appropriate/ inappropriate (to season and situation)/ neat and tidy/ dirty. Posture: Relaxed, strange/ odd posture, tensed, catalyst, waxy flexibility.

29. Psychomotor Activity: Increased/decreased/ Compulsive/echopraxia/ Stereotypy/ negativism/ automatic obedience Mannerisms: stereotype, negativism, tics, normal. Eye to eye contact: Normal eye contact, hesitant, starring at the examiner. Rapport: built easily, not built, built with difficulty. Behavior: includes social behavior, E.g. Overfriendly, disinherited, preoccupied, aggressive, normal. Physical features: - look older/ younger than his or her age/ under weight/ over weight/ physical deformity.

30. II. Speech One sample of speech (verbatim in 2 or 3 sentences) Coherence-coherent/ incoherent Relevance (answer the questions appropriately) – relevant / irrelevant. Volume (Intensity):soft, loud or normal Tone :high pitch, low pitch, or normal/ monotonous Manner – Excessive formal / relaxed/ inappropriately familiar. Reaction time (time taken to answer the question) – increased, decreased or normal Deviation : Rhyming, Echolalia, Neologism, Verbigeration, circumstantiality, Tangentiality, Stereotype, Clang association, flight of ideas

31. III. Mood (subjective) and Affect (objective) Mood: Subjective: Can be assessed by asking questions related to mood Interpretation: Appropriate/ inappropriate (Relevance to situation and thought congruent). Affective: Is made by observing the facial expression of the patient Interpretation :Pleasurable affect(Euphoria / Elation / Exaltation/ Ecstasy),Unpleasurable affect- (Grief/ mourning / depression.),Other affects- Anxiety / fear / panic/ free floating anxiety/ apathy/ aggression/ moods swing/ emotional liability

32. IV. Perception: A) Illusion B) hallucinations- (specify type and give example) – auditory/ visual/ olfactory/ gustatory/ tactile C) others- hypnologic/ hypnopompic/ lilliputian/ kinesthetic/ macropsia/micropsia

33. Hypnagogic hallucinations are imagined sensations that seem very real. They occur as a person is falling asleep, and are also referred to as sleep hallucinations. Lilliputian  hallucination :  An hallucination in which things, people, or animals seem smaller than they would be in real life. Lilliputian refers to the "little people" who lived (fictionally) on the island of Lilliput in Jonathan Swift's 1726 masterpiece  Gulliver's Travels . Kinesthetic hallucination: It is false perception of movement or sensation as from phantom limb. Macropsia: It is state in which the objects appears larger than they are. Micropsia: It is state in which objects appears smaller than they are.

34. V. Thought a) Form of thought/ formal thought disorder – not understandable / normal/ circumstantiality/ tangentiality/ neologism/ word salad/ preservation/ ambivalence. b) Stream of thought/ flow of thought- pressure of speech/ flight of ideas/ thought retardation/ mutism/ aphonia/ thought block/ Clang association. c) Content of thought Delusions- (specify type and give example) - Persecutory/ delusion of reference/ delusions of influence or passivity/ hypochondriacal delusions/ delusions of grandeur/ nihilistic- Derealization/ depersonalization / delusions of infidelity. Obsession ideas, Phobias, Preoccupation, & Depressive ideas Peculiar ideas about interpersonal relation ship

35. VI. Cognitive functions (Higher mental function) a) Consciousness: conscious/ unconscious/ drowsy b) Orientation: a. Time _approximately without looking at the watch, what time is it? b. Place – where he/she is now? c. Person – who has accompanied him or her?

36. c) Attention and concentration Check whether it is easily aroused and sustained. Does he concentrate or easily distract Method of testing (asking to list the months of the year forward and backward) Serial subtractions (100-7) d) Memory A) immediate (teach an address & after 5 mts. Asking for recall) B) recent memory – 24 hrs. Recall C) remote: asking for dates of birth or events which are occurred long back I) amnesia/ paramnesia/ retrograde amnesia/ anterograde amnesia Ii ) confabulation Iii ) ‘déjà vu’/ jamain vu Iv) hypermnesia

37. E) abstract thinking Give a proverb and ask the inner meaning (E.g. feathers of a bird flock together/ rolling stones gather no mass) Similarities and differences between familiar objects should be asked. ( E.g.:- Table and chair/Banana and orange/ tiger and cat) F) insight Grade-I- Complete denial of illness Grade-II-Slight awareness of being sick Grade-III-Awareness of being sick attributes it to external / physical factor. Grade-IV-Awareness of being sick, but due to some thing unknown in himself. Grade-V-Intellectual insight Grade-VI-True emotional insight

38. G) Judgment Personal (future plans) Social (perception of the society) Test (present a situation and ask their response to the situation) Interpretation: See for Logic/Illogic judgment H) Intelligence & General Information: (Based on his educational background) Test by arithmetic calculation General knowledge Digit score test Reading and writing

39. VIII Special point Sleep i )Insomnia – temporary/ persistent ii) Hypersomnia – temporary/ persistent iii) Non-organic sleep- wake cycle disturbance iv) EMA- Early Morning Awakening Episodic disturbances – Epilepsy/ hysterical/ impulsive behavior/ aggressive behavior/ destructive behavior Appetite: Bowel and bladder habits:  http://www.merckmanuals.com/professional/neurologic-disorders/neurologic- examination  ...

40. MINI MENTAL STATE EXAMINATION

41. The mini mental state examination is a cognitive test used to screen for the presence of cognitive impairment. USES OF MSE… — It provides measures of orientation, registration & short-term memory, attention, voluntary movement & language functioning. — The shortened version of the minimental state examination is an accurate predictor of dementia. MINI MENTAL STATE EXAMINATION

42. COMPONENTS OF MMSE Orientation Registration Attention Calculation Recall Language etc.

43. SCORING… It is a reliable test, with score of 25-30 considered normal, 18-24 indicative of mild to moderate, scores of 17 or less correlate with substantial impairment in activities of daily living. Social background, educational level & verbal ability can influence results & should be taken into account in their interpretation.

44. NEUROLOGICAL EXAMINATION IN PSYCHIATRY

45. INVESTIGATION IN PSYCHIATRY

46. Investigation are useful to detect alteration in biologic function & to screen for medical disorders causing psychiatric symptoms.

47. ROUTINE INVESTIGATION A complete hemogram (total & differential blood count, haemoglobin, ESR) & urine analysis are basic routine tests. Leucopoenia & agranulocytosis are associated with certain medications (clozapine). Treatment with lithium & neuroleptic malignant syndrome are often associated with leucocytosis. Renal function tests: Treatment with lithium. Liver function tests: For all alcoholic patients treatment with carbamazepine, valproate & benzodiazepines. Serum electrolytes: Dehydration, treatment with carbamazepine, antipsychotics, lithium

48. Blood glucose: Routine screen above 35 years age Thyroid function test: Depression, treatment with lithium & carbamazepine. Electrocardiogram (ECG): Above 35 years of age, treatment with lithium, antidepressants, ECT, antipsychotics. HIV testing: IV drug users, suggestive sexual history, AIDS, dementia. VDRL: Suggestive sexual history Serum CPK: Neuroleptic malignant syndrome ( markedly increased levels) Chest X-ray: Before treatment with ECT Drug level estimation: Drug levels are indicated to test for therapeutic blood levels, for toxic blood levels & for testing drug compliance. Examples are lithium (0.6-1.6 mEq /L), carbamazepine (6-12 mg/ml, valproate (50-100 mg/ml), haloperidol (818 mg/ml), imipramine (200-250mg/ml), etc)

49. ELECTROPHYSIOLOGICAL TESTS Electroencephalogram (EEG): Measures brain electrical activity, identifies dysrhythmias & asymmetric, used in the diagnosis of seizures, dementia, neoplasm, stroke, metabolic or degenerative disease. Polysomnography/sleep studies: Used in the diagnosis of sleep disorders & seizures.

50. BRAIN IMAGING TESTS Computed Tomography (CT) scan: Measures accuracy of brain structure to detect possible lesions, abscesses, areas of infarction or aneurysm. CT scan also identifies various anatomic differences in patients with schizophrenia, organic mental disorder & bipolar disorder. Magnetic Resonance Imaging (MRI) scan: Measures the anatomic & biochemical status of various segments of the brain; detects brain edema , ischemia, infection, neoplasm, trauma & other changes such as demyelination used in the diagnosis of dementia, to detect morphological changes in schizophrenia patients. Other tests are Positron Emission Tomography (PET)

51. NEURO-ENDOCRINE TESTS Commonly used neuro-endocrine tests are dexamethasone suppression test, TRH stimulation test, serum prolactin levels serum 17-hydroxycorticosteroid, serum melatonin levels. GENETIC TESTS Cytogenetic work-up is advised in some cases of mental retardation.

52. PSYCHOLOGICAL TESTS