4 nursing priorities
criteria to diagnose:
1. essential features
2. associated features
3. a specific time frame during which these features have occurred
4. signs and symptoms cause significant impairment to person's ability to fnxn
DSM 5 axes of the multi axial assessment
I. Clinical disorders
II. Personality disorders/intellectual delay
III. General Medical Conditions
IV. Psychosocial and Environmental Problems
V. Global Assessment of Functioning
I. Clinical disorder
-the mental illness being treated
-may have more than one diagnosis
(schizophrenia, depression, etc)
II. Personality Disorders or Intellectual Delay
-more stable characteristics, unchanging
-their personality and intellectual capacity
(intellectual delay, borderline, antisocial)
III. General Medical conditions
HTN, HIV, etc.
IV. Psychosocial Stressors
-problems with family support
-problems R/T social environment
V. Global assessment of functioning
-clinician's subjective rating of how likely the client is to function in society at this moment
-0 to 100
social ecological model of health
psychological strategies brought into play by individuals and groups to cope with reality and maintain self image
-protective in nature
-used for overwhelming anxiety
-reactionary and automatic
healthy use of defense mechanisms
-used to integrate conflicting emotions and thoughts while still remaining effective
types of healthy defense mechanisms (4)
constructive service to others that brings pleasure and the personal satisfaction and is not compensatory
realistic planning for future discomfort
unconscious modeling of one's self upon another person's or group's character and behavior
-pushing thoughts into the preconscious short term, for coping at the present time
-you are aware that you are doing this, and you are able to come back and address the thoughts
refusing to accept or believe reality
in psychoanalytic theory, the basic defense mechanism that banishes from consciousness anxiety-arousing thoughts, feelings, and memories
-behave in a way that is the exact opposite of your true feelings
ex: Jane hates nursing but attended school to please her parents and speaks about the excellence of her career
a defense mechanism by which your own traits and emotions are attributed to someone else
-you are attracted to someone else and tell your friends "he is coming on to me"
justifying personal actions by giving "rational" but false reasons for them
diverting emotional feelings (usually anger) from their original source to a substitute target
bolstering self-esteem by forming an imaginary or real alliance with some person or group
covering up felt weaknesses by emphasizing some desirable characteristic, or making up of frustration in one area by over-gratifying another
-atoning for or trying to magically dispel unacceptable desires or acts
-the actual issue isn't addressed, just nice things are said or done instead
Mental status exam
-collates information about the client's physical, emotional, and cognitive state
-the mental head to toe
MSE: physical (3)
3. motor activity
MSE: emotional (2)
2. mood and affect
MSE: cognitive (8)
4. insight and judgement
5. attention and concentration
6. speech and language
8. intelligence and abstraction
are they put together and groomed?
are they alert? in a stupor? what are their mannerisms?
motor activity (4)
1. bradykinesia (think Eyore)
4. psychomotor agitation (think Tigger!)
mood and affect
-affect: external expression of an emotional state
-mood: internal emotional experience that influences perception and actions
mismatch btwn mood and affect
(someone who says they are really happy but is talking in a low, depressed sounding voice)
how stable is their mood?
euphoric, dysphoric, hostile, apprehensive, fearful?
person, place, time, situation
attention and concentration
-ability to focus
-are they distractible? Do they go off on tangents?
-have them do a digit span or serial sevens
give them a series of numbers and have them repeat it backwards
have them count backwards from 100 by sevens
1. short term: who is the president?
2. visual short-term: draw something and have them draw it
3. long-term: ask about childhood events
thought (form and content)
how fast are they producing their thinking?
are their thoughts tangental? loose associations?
similar to circumstantial thought, but person never returns to central point nor answers original questions
one word in the sentence is related to the next thought
a false fixed belief despite objective contradictory evidence
-they aren't going to change their mind- just try and redirect the behavior
-are there hallucinations?
perceptual disturbance related to the 5 senses
-most usually auditory
The loss of one's sense of reality of the outside world. Examples: things may seem to change size or shape; people may seem mechanical.
person doesn't feel like they are real
insight and judgement
insight- are they aware they have a problem?
judgement- the ability to make sound decisions
speech and language
is it slow or rapid? aphasia?
intelligence and abstraction
do they have a general fund of knowledge? do they have intellectual delay?
ability to recognize and comprehend abstract relationships
primary focus of MSE
Squarely face client
Establish eye contact
using touch in a mental health setting
be aware of the hypersensitivity of some clients
-they may interpret it as a sexual invitation
-invasion of space
-a written report of verbal interaction with the client
-paraphrase as best as you can and be sure to include their actions and mannerisms
-usually temporary or reversible
-often caused by withdrawal, drug abuse, electrolyte imbalance, pneumonia, UTIs, post-op
-acknowledging and indicating awareness
-encourages client to continue
-"yes, I see,"
-verbalizing client behaviors
"you seem tense"
-lets the client know you are listening and allows for clarification
-questions and feelings are referred back to the client
-good way to avoid giving advice
-delving further into subject matter
-used when a client is having hallucinations, etc, you tell them what you observe
-expressing uncertainty in the client's perceptions
"I find that hard to believe"
giving approval or disapproval, giving advice, or agreeing/disagreeing
-persistent questioning of a subject the client doesn't want to discuss
"no one here would lie to you"
requesting an explanation
"why do you think that?"
indicating the existence of an external source of power
-"what makes you say that? What made you do that?"
-allows the client to pass blame
client says: "i'm nothing"
you say: "of course you are something! Everybody is somebody."
you SHOULD say, "you feel like nobody cares about you right now"