Chapter 8 MH

picture of client's current emotional state, mental capacity, behavioral function -> client's baseline
basis for developing plan of care
clinical baseline to evaluate effectiveness of treatment or measure client's progress

client participation/feedback
client's health status
client's previous experiences/misconceptions about health care
client's ability to understand
nurse's attitude and approach

comfortable, private, safety
quiet with few distractions

information about their perceptions of client
information limited by certain factros

open-ended to initate assessment
focused if client cannot organize thoughts or has difficulty answering open-ended questions
an anxious person may need direct questions

Are you thinking of killing yourself?

age
developmental stage
cultural considerations
spiritual beliefs
previous history -> medications they are on

hygiene/ grooming -> know by observing not asking
appropriate dress -> active mania = bizzare dress
posure
eye contact
unusual movement/mannerisms -> automatisms (repeated purposeless behaviors often = anxiety tapping foot, psychomotor retardation (overall slow movements), waxy flexibility (maintenance of posture or position over time even when it is awkward or uncomfortable)
speech -> neologisms (invented words only have meaning to themselves)

mood is feeling
affect is how its coming across

assess for consistency -> looking to see if congruent
blunted -> showing little or slow-to-respond facial expressions
broad -> displaying a full range of emotional expressions
flat -> showing no facial expressions
inappropriate -> displayingn a facial expression that is incongruent with mood or situation; silly ot giddy regardless of circumstances
restricted -> displaying one type of expression, usually serious or somber
labile -> rapidly unpredictable mood swings

process is how you think
content is what the pt says

circumstantial thinking -> eventually answers a question but only after giving excessive unnecessary detail
delusional -> fixed fall belief not based in reality
flight of ideas -> excessive amount and rate of speech composed of fragmented or unrelated ideas
ideas of reference -> client's inaccurate interpretation that general events are personally directed to them, believing speech on news was for them personally
loose associations -> disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts
tangential thinking -> wandering off the topic and never providing info requested
thought broadcasting (delusional belief others can hear or know what client is thinking, insertion (delusional belief others put ideas in head, blocking (stopping abuptly in middle of sentence or train of thought, withdrawl (delusional belief that others are taking client's thoughts away)
word salad -> content w/ disorganized thought process, words that mean nothing at all

are you thinking of killing yourself?
do you have a plan to kill yourself
how do you plan to kill yourself
how would you carry out this plan and do you have the means to carry out
when do you plan to kill yourself
what day or time of day do. you plan to kill yourslef

duty to warn
don't have to inform family unless someone has power of attorney

orientation -> oriented to person, place and time, important to know which ones
memory -> "what is the name of the current president" or "what county do you live in" or "what is the capital of this state"
ability to concentrate -> spell world backwards
abstract thinking and intellectual abilities -> "wears heart on sleeve" someone may think literal heart on sleeve if cant abstract think

auditory hallucinations
visual hallucinations
do you see or hear things and what are they telling you

ability to interpret environment
ability to understand true nature of one's situation
judgment -> do you spend more money than you have
insight -> understand nature of their illness
poor insight -> "i'm fine nothing is wrong" when whole family has left

personal worth and dignity
description of physical characteristics/ body image
emotions the client frequently experiences

current roles -> who do you live with and is it a supportive environment
ability to fulfill roles
change in roles
satisfaction with relationships
online activity/social media
caregories of family assessment

eating habits -> eating disorder
sleeping patterns -> sleeping a lot or very little
major or chronic health problems
use of drugs and/or alcohol -> is it problematic, how much and how often
medication nonadherence

overall assessment
not isolated bits of information
patterns or themes in data -> conclusion about clients' strengths and needs, problems and risks
ongoing, dynamic process

cognitive abilities
intellectual functioning

self-concept, impulse control, reality testing, major defenses
objective
projective

interpretation of proverbs
math calculations
memorization, short-term recall
identification of common objects
ability to follow multistep commands
ability to write or copy a simple drawing

be open, clear, direct when asking about personal or uncomfortable topics