ASSESSMENT OF THE MENTALLY ILL PATIENT

Assessment involves determining what to assess and how to make a diagnosis.

Components of Assessment

1. Taking History.
2. Psychiatric Assessment (includes Mental State Examination).
3. Physical Examination.
4. Request for Investigations (e.g., biological (blood, urine, X-ray), psychological, social investigation (home visit), and environmental investigation).

Conditions During Consultation (Setting the Stage)

• Time should be sufficient.
• There should be privacy.
• The consultation room should be tidy. An untidy room can influence negative information.
• No other interferences (e.g., answering telephone calls) should occur, as this makes the patient uneasy.
• Health Worker Appearance: The decoration of the health worker (e.g., finger, eyebrows, lips, head) should be considered.
• Establishing Therapeutic Relationship (Rapport): The quality of information depends on the confidentiality and trustworthiness the patient sees in you. A patient will not share personal and diagnostically important information with someone they do not trust. Rapport is a basic, understanding, and trusting relationship between the patient and the nurse/clinician.

HISTORY TAKING

1. DEMOGRAPHIC DATA (PARTICULARS):
   • Name, Age, Sex, Marital status, Address.
2. SOURCE OF REFERRAL:
   • Who and why they referred the patient.
   • Who is available to give collateral information and whether that history is judged reliable.
3. PRESENTING COMPLAINTS:
   • This is a short statement, numbered, with appropriate duration, and chronologically written.
4. HISTORY OF PRESENTING COMPLAINTS:
   • Elaborate on the presenting complaints, focusing on those of medical importance.
5. PAST PSYCHIATRIC HISTORY:
   • Has the patient ever suffered from any mental illness before? If so:
     • When, where, and treated by whom?
     • What were the signs and symptoms?
     • For how long and the outcome of the treatment?
     • How the patient has been functioning between the attacks of the illnesses.
6. PAST MEDICAL AND SURGICAL HISTORY:
   • Any serious physical illness (e.g., T.B, HIV/AIDS).
   • Any serious accident, blood transfusion.
7. FAMILY HISTORY:
   • Name, age, and health status of parents.
   • Whether any family member has ever suffered from any mental illness.
   • Relationship of patient and parents.
   • If dead, when, how, and the effect to the patient.
   • Information also sought from siblings.
8. PERSONAL HISTORY:
   • Before Birth: Wanted pregnancy? Suffered illness or took drugs during pregnancy?
   • Delivery: Complication or normal.
   • Developmental Milestone attainment.
   • School History: When did they join? School attended? Grade attained? Any position of responsibility held? If changed school, why?
   • Puberty and Adolescence History: Psychological effects.
   • Menarche (Females): Age of onset. Was she prepared, or was it a surprise?
9. SEXUAL HISTORY:
   • From whom did the patient learn about sexual matters?
   • When did the patient start having sex?
   • Is the patient able to enjoy sex or are there sexual deviants?
10. MARITAL STATUS:
    • To whom is the patient married, when, for how long? If separated, why?
    • Whether they have children.
    • Any marital problems.
    • Relationship between the man and the woman.
11. OCCUPATIONAL HISTORY:
    • What kind of work is the patient doing? Do they want it or just found themselves there?
    • Relationship with workmates.
    • Is the salary enough for the patient?
12. FORENSIC HISTORY:
    • Whether the patient has been in trouble with the law.
13. PREMORBID PERSONALITY:
    • How other people describe the patient before being mentally sick.
14. HOBBIES: Free time occupations.
15. HABITS: Such as smoking cigarettes, use of alcohol or other substances.

MENTAL STATE EXAMINATION (MSE)

MSE is a systematic appraisal of the appearance, behavior, mental functioning, and overall demeanor of a person.

Appearance

• Provides clues into their quality of self-care, lifestyle, and daily living skills.
• Note distinctive features, clothing, grooming, and hygiene.

Behavior

• Note what the person is doing and non-verbal communication. These can reveal much about a person’s emotional state and attitude.
• Observations: 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 behavior, psychomotor activity and movement (e.g., hyperactivity, hypoactivity), and 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: (e.g., ecstatic, elevated, lowered, depressed).
• Irritability: (e.g., explosive, irritable, calm).

Speech

Speech should be described behaviorally as well as considering its content. Unusual speech is sometimes associated with mood and anxiety problems, schizophrenia, and organic pathology.

• 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.

• Level of consciousness: (e.g., alert, drowsy, intoxicated, stuporous).
• Orientation to reality: Awareness of the time/day/date, where they are (place), and ability to provide personal details (person).
• Memory functioning: Includes 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 and thought process.

• Content (Nature of Thoughts):
  • Delusions (rigidly held false beliefs not consistent with 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 catastrophic outcome, often indicated by associated compulsive behavior).

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.e3e3

Hallucinations

Hallucinations are arguably the most widely known form of perceptual disturbance. For the individual experiencing them, hallucinations are indistinguishable from reality. They can affect all sensory modalities, though auditory hallucinations are the most common.

• In children, it’s common to experience self-talk or commentary as an internal “voice.”
• Command hallucinations (voices instructing the person to do something) require thorough investigation.
• It’s important to note the degree of fear and/or distress associated with the hallucinations.

Insight

Insight refers to the patient’s acknowledgement of a possible mental health problem. This includes their understanding of potential treatment options and their ability to comply with those treatments.

Judgment

Judgment refers to a person’s problem-solving ability in a more general sense. It 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 Assessment and Nursing Care Planning

Physical Examinations

The physical assessment component includes:

• Vital Observations (Vitals)
• Systemic examination
• Carrying out investigations if deemed necessary.

Develop the Nursing Care Plan

The process for developing, implementing, and evaluating the care plan involves several critical steps:

• Group the findings into objective and subjective data.
• Formulate the Nursing Diagnosis (identifying the patient’s needs).
• Identify the goals, methods, and resources to be used.
• Implement the nursing care plan.
• Evaluate the care plan.