The Psychiatric Nursing Assessment Christine Carniaux-Moran 3

© Jones and Bartlett Publishers. NOT FOR SALE OR DISTRIBUTION

CHAPTER The Psychiatric Nursing Assessment Christine Carniaux-Moran 3

LEARNING OBJECTIVES

After reading this chapter, you will be able to: · Demonstrate an understanding of the role of · Identify the components of a holistic psychological testing, including rating scales, assessment, including mental status in assessment. examination. · Demonstrate understanding of each of the fi ve · Correctly use psychiatric terminology to axes in a DSM-IV-TR diagnosis. describe a client’s symptoms. · Choose the appropriate interviewing techniques to gather information for a holistic assessment.

KEY TERMS

Affect Homicidal thoughts Biopsychosocial history Impulse control Chief complaint Insight Closed-ended questions Judgment Collateral history Mental status examination Concrete thought process Mood Coping skills Multiaxial DSM-IV-TR diagnosis Countertransference Open-ended questions Delusions Physical assessment Differential diagnosis Psychiatric nursing interview Diagnostic and Statistical Manual of Mental Psychological tests Disorders, 4th ed., text revision (DSM-IV-TR) Resistance Empathy Self-disclosure Global assessment of functioning scale Suicidal thoughts Hallucinations Therapeutic contract History of present illness (HPI) Transference Holistic psychiatric assessment

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Introduction Cognitive functioning is best assessed by utilizing a standard measure such as the Mini-Mental State The evaluation of psychiatric clients is a multifac- Examination. The social assessment consists of eted endeavor, most effectively performed by an an exploration of cultural, environmental, and interdisciplinary team of mental health profes- familial infl uences on the expression and experi- sionals. A comprehensive, holistic psychiatric as- ence of illness, and the spiritual assessment is an sessment examines the physical, psychological, exploration of the client’s religious and spiritual intellectual, social, and spiritual aspects of the in- dimensions (Table 3-1). dividual. The physical assessment may include a The psychiatric nursing evaluation covers the physical examination, a study of the client’s bio- assessment, diagnosis, outcome identifi cation, and logic life stage and genetic predisposition, labora- planning stages of the nursing process. The evalua- tory tests, and diagnostic tests such as magnetic tion is ongoing; as more of the client’s history and resonance imaging (MRI) and electroencepha- new insights into his or her issues come to light, the lography (EEG). The psychological evaluation diagnosis and treatment plan evolve accordingly. surveys childhood experiences, personality, and current objective and subjective symptoms of psychiatric illness. This information is gathered Assessment by interviewing the client and family, by perform- The ability to assess clients is one of the psychiat- ing a mental status examination, and by adminis- ric nurse’s most important skills. The assessment tering specifi c psychological tests and rating scales. process defi nes the client’s problem and allows

Table 3-1 Holistic Psychiatric Nursing Assessment

Assessment Tool Component Parts Dimension Addressed Biopsychosocial history Chief complaint Psychological History of present illness Psychological Psychiatric history Psychological Alcohol and substance use history Psychological Medical history Physical Family history Psychological, physical, social Developmental history Psychological, physical, social Social history Social Occupational/educational history Social Culture Social Spirituality Spiritual Coping skills Psychological Mental status examination Behavior and appearance Psychological, physical, social Emotions: mood and affect Psychological Speech Psychological, physical, social, intellectual Thought process and content Psychological, social, intellectual, spiritual Perceptual disturbances Psychological, physical Impulse control Psychological, physical Cognition and sensorium Intellectual, physical Knowledge, insight, and judgment Intellectual, psychological Psychological tests Multiple tools, including rating scales Psychological, intellectual Physical assessment Physical examination Physical Assessment of activities of daily living Physical Laboratory tests Physical CT scans/other diagnostic tests Physical

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the nurse and client to establish a relationship. A The content and process of the interview vary thorough nursing assessment is a prerequisite for according to the state of the participants and the formulating an appropriate nursing diagnosis context in which the interview takes place. For and plan of care. Assessment data also provide a example, an agitated client has just been admitted baseline level of functioning that is used to evalu- to an acute psychiatric unit of a teaching hospital. ate, change, and respond to the treatment plan. The client’s severe impairment, the nurse’s need Data used for assessment are gathered not to budget time, and the busy nature of the setting only from the client, but also from other sources. indicate that a series of brief, structured inter- The client’s self-assessment usually differs from views is the most viable approach. The members the perception of family, coworkers, other clients of the interdisciplinary treatment team (psychia- in the hospital, and members of the treatment trist, nurse, social worker, and other specialists) team; those views also vary between groups. Ad- share the responsibility for data collection. With ditionally, anyone’s perception of the client will consent, family or signifi cant others may be ap- change over time. proached to elucidate the client’s story. The con- Assessment guidelines vary according to the tent of the initial interview should focus on elicit- specifi c dimensions of the client being evaluated; ing information to help the staff provide a safe however, the need for a structured interview and environment for the client and others (i.e., the a data collection tool is widely accepted. Tools client’s potential for suicidal and violent behavior and guidelines for performing comprehensive is assessed). nursing assessments assist in evaluating clients, The content of the psychiatric nursing inter- improve the nurse’s professional image, and view focuses on the client’s biopsychosocial his- increase job satisfaction (Catherman, 1990). tory and current mental status. Lengthy assessment tools are often met with re- sistance by staff nurses who struggle with time Content of the Psychiatric Nursing constraints in the workplace (Schreiber, 1991). This resistance is partially justifi ed by shorter Interview: Biopsychosocial History stays in the hospital, increased client acuity, and Biopsychosocial history is a comprehensive as- fi nancial pressure to decrease the nurse-to-client sessment of the client’s lifetime biologic, psycho- ratio throughout the healthcare system. logical, and social functioning. Nurses must narrow the range of their data collection to the information judged most rele- Identifying Data vant. It is the quality and not the quantity of the A written biopsychosocial history begins assessment data that matters (Regan-Kubinski, with a succinct summary of the client’s demo- 1995). The following guidelines for a holistic psy- graphics: name, age, gender, marital status, eth- chiatric nursing assessment should be tailored to nicity, religion, occupation, education, and cur- meet the specifi c needs of the nurse, client, and rent living situation. situation. These guidelines provide instructions for conducting a psychiatric nursing interview to Chief Complaint obtain data for a biopsychosocial history and men- The client’s chief complaint is the reason for tal status examination. current contact with the mental health system. The chief complaint should be obtained in the client’s Psychiatric Nursing Interview own words. Because of the nature of the illness, the client’s statement may differ greatly from the fam- An interview is a conversation with a deliberate ily’s or evaluator’s assessment of the situation (e.g., purpose that ideally is mutually accepted by the an in-patient insists that she is in the hospital for participants. It differs from a social conversation in a medical checkup following her abduction by that one participant (the nurse) is responsible for aliens). The chief complaint provides valuable data the content and fl ow of the interaction, while the concerning the client’s illness. other participant (the client) is the focus of the dis- cussion. The interview must take place within a History of Present Illness specifi c time frame. The purpose of the psychiatric The history of present illness (HPI) is a chrono- nursing interview is to gather the information nec- logic account of the events leading up to the cur- essary to understand and treat the client. rent contact with the mental health professional.

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The HPI includes a description of the evolution of mental illness or may represent a client’s attempt the client’s symptoms that covers the onset, dura- to cope with a preexisting mental disorder. Re- tion, and change of symptoms over time. Exacer- search has shown that drug and alcohol use in the bating and ameliorating factors of the current mentally ill adversely affects the course of their psychological distress must be explored, and the illness (Sadock, Kaplan, & Sadock, 2003). nurse should delineate factors that may have pre- The nurse should obtain a history of the cli- cipitated the current episode. These stressful ent’s caffeine and nicotine use; both are prevalent events may be negative (e.g., job loss) or positive in psychiatric clients. Caffeine may supply energy (e.g., job promotion). Attendant changes in so- to depressed and schizophrenic clients; caffeine matic functioning (sleep pattern, appetite, cogni- and caffeine withdrawal may cause agitation as tive ability, sexual functioning) should also be well. Nicotine use may increase attention span noted. This information is similar to that obtained and memory in clients with schizophrenia but when clients are evaluated for nonpsychiatric may decrease the effi cacy of neuroleptics. Nico- medical illnesses (see Table 3-2). tine withdrawal may lead to agitation or depres- sion (American Psychiatric Association [APA], Psychiatric History 2000; Rauter, de Nesnera, & Grandfi eld, 1997). Information concerning past psychiatric ill- ness must be obtained to understand the current Medical History episode, to make an accurate diagnosis, and to The nurse should ascertain signifi cant ill- make a prognosis. Psychiatric illness may be a nesses, injuries, and treatments received. The cli- single event, chronic, or intermittent, and the ent must be assessed for allergies and past and course of the illness may improve or deteriorate present side effects from medication. An Abnor- over time. mal Involuntary Movement Scale (AIMS; Guy, 1976) examination may be done to measure psy- Alcohol and Substance Use History chotropic medication–induced motor side ef- Studies have shown high co-morbidity of fects. In performing an AIMS examination, the mental illness and alcohol or substance abuse. nurse observes for abnormal muscle movement Causality is diffi cult to discern, because alcohol while the client performs a series of simple motor and drug abuse may precipitate an episode of tasks. Women should be questioned concerning

Table 3-2 Comparison of Assessment for Physical and Mental Disorders

Chief Complaint Angina Depression Quality “Chest tightening, with pain radiating down “Emotional pain that feels like I am my left arm.” going to die.” Severity “Severe—a 9 on a scale of 1 to 10.” “Severe—a 9 on a scale of 1 to 10.” Timing “It lasts about 5 minutes.” “It is constant.” History of Present Illness Angina Depression Factors that aggravate Exercise, emotional stress, and meals Stress at work, arguments with family members, and morning hours Factors that alleviate Rest and nitroglycerine tabs Social contact, activities, and antidepressant medication Associated symptoms Dyspnea, nausea, and sweating Anhedonia (chronic inability to experience pleasure), diminished appetite, and insomnia Chronology Started with chest pain on exertion 1 year Started with a sad mood and feeling ago; getting increasingly more severe and overwhelmed after a job promotion frequent 6 months ago; getting increasingly more incapacitating and unrelated to life events over time

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their menstrual cycles, pregnancies, and meno- Clinical Example pause; hormonal changes may have a signifi cant Jerry is a 34-year-old male diagnosed with chronic paranoid schizophrenia, impact on the client’s mental health. The nurse brought to the hospital by the police after threatening to harm passersby on should evaluate the client’s risk for falling and the street. Jerry became enraged when he discovered that the hospital was skin breakdown and take note of assistive devices a smoke-free environment; he had been smoking one to two packs of ciga- the client requires (e.g., eyeglasses, hearing aides, rettes per day for 15 years. Jerry was offered treatment with a nicotine patch dentures, canes, walkers). or gum; however, he adamantly refused this treatment. Jerry required phys- ical restraint on one occasion and medication on several other occasions, Family History due to psychotic agitation that was exacerbated by nicotine withdrawal. Families are no longer blamed for causing Jerry was stabilized on psychotropic medications and was discharged within mental illness; rather, they are taught about the 2 weeks. Upon discharge, Jerry resumed smoking and had a relapse of psy- condition and engaged in the treatment process. chotic symptoms. His psychiatrist attributed the outpatient decompensa- Obtaining a family history of mental illness is im- tion to the diminished efficacy of the antipsychotic medication, because the portant, because many of these disorders are he- medication dose had been titrated in the hospital while Jerry was nicotine- reditary. Bipolar and unipolar mood disorders, free. Jerry’s condition was stabilized with an increase in dose. schizophrenia, and attention defi cit disorder (ADD) have signifi cant genetic components. The client’s response to specifi c interventions may be Traumatic Stress Network, 2004). Data show that inherited as well, and should be included in the 34–53% of the mentally ill population report family history (Sadock et al., 2003). childhood sexual or physical abuse, with a 29– 43% rate of PTSD among the seriously mentally Developmental History ill (Kessler et al., 1995). The developmental history is an account of the client’s infancy, childhood, and adolescence. Social History It may provide clues to the origin of current be- A client’s ability to make and sustain relation- haviors and aid in the diagnosis. Erikson (1963) ships indicates the ability to utilize the therapeu- created a developmental timetable to identify the tic relationship and aids in the diagnosis. Larger psychosocial adaptation required during each social networks are correlated with decreased se- stage of life. All stages, beginning with birth and verity of mental illness and a more thorough re- extending through senescence, are characterized covery. It is often diffi cult to ascertain whether a by developmental tasks. The successful comple- client’s social problems have precipitated or re- tion of these tasks, crucial to both happiness and sulted from the mental illness. success with subsequent tasks, represents optimal The psychiatric nurse should inquire about adaptation at a given stage. In contrast, failure at the client’s family and household members. How these tasks may lead to diffi culty completing fu- have family and signifi cant others responded to ture tasks and may stifl e psychosocial growth. the client’s illness? Often, a family member’s men- Self-esteem, self-control, and independence tal illness is extremely disruptive to the family sys- emerge during toddlerhood, peak during the in- tem (Terkelson, 1987). Seek the client’s permis- dustry versus inferiority stage (6 years of age sion to involve family members and signifi cant through puberty), and represent key issues in as- others in the assessment and treatment process, sessing an adult’s ability to cope with the stress of unless this involvement would be counterproduc- illness, for example (see Table 3-3). tive. Ascertain a history of the client’s friendships Childhood mental disorders, temperament, and sexual partners. and style of interpersonal relationships may re- The nurse should have the client describe main with the client into adulthood. Additionally, these relationships or lack thereof. Is the client psychic trauma (e.g., neglect or abuse, loss of par- satisfi ed with his or her social role at this point in ent) experienced by a client during childhood life? For example, some persons become distressed may adversely affect brain development, leading when they fail to accomplish social milestones to impulse control problems, personality disorder, such as marriage by a certain age. Assess the posttraumatic stress disorder (PTSD), depres- client’s wider social network, including religious sion, or other psychiatric illness (Terr, 1991). It is organizations, community centers, and clubs. The estimated that 25% of children under age 16 will client’s living situation is also integral to the experience some kind of trauma (National Child assessment, because many of the client’s stressors

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Table 3-3 Erikson’s Stages of Psychosocial Growth and Development

Age Group Developmental Stage Task Characteristics Infancy Trust vs. mistrust The goal is the development of a sense of trust. Consistent attention to physical needs within a reasonable time period builds trust. Toddlerhood Autonomy vs. shame and The goal is the achievement of autonomy. An environment in which doubt the child is able to explore surroundings in a safe way engenders autonomy. Successful toilet-training plays a key role. Preschool age Initiative vs. guilt The goal is the development of a sense that the child’s actions produce outcomes through opportunity to try to do things on one’s own. School age Industry vs. inferiority The goal is a feeling of self-worth, gained by mastering schoolwork, sports, and other competitive activities. Adolescence Identity vs. role confusion The goal is to establish a unique identity, first by rejecting adults and identifying with peer group and later by developing individuality. Young adulthood Intimacy vs. isolation Establishment of close relationships with members of both sexes. Middle adulthood Generativity vs. stagnation The goal is a feeling of giving back to the younger generation or society, through successfully adjusting to changing roles in marriage, parenting, and career. Late adulthood Integrity vs. despair The goals are to attain a sense of continuity of past, present, and future, of meaning in one’s life as it was, and of acceptance of death. This is achieved through life review and reminiscence.

are environmental in origin. Homelessness, for school. The client’s level of education partially example, is a severe social stressor (see Figure 3-1). determines how the nurse can most effectively communicate with and educate the client. Low Occupational and Educational History socioeconomic status has been correlated with a It is essential to establish a client’s past and relatively high rate of symptoms of mental illness present level of function in work and school. A (Gresenz, Sturm, & Tang, 2001). sporadic or chaotic employment history may in- dicate personality disorder or frequent episodes Culture of mental decompensation. Work- or school- Ethnicity, race, social class, degree of accultur- related stress may have precipitated the illness. ation, and language should be included in the cul- Assess the impact that hospitalization or treat- tural assessment. Culture can signifi cantly infl u- ment may have on the client’s function at work or ence the development, expression, and reporting of mental disorders; thereby affecting diagnosis. A clinician who is unfamiliar with the nuances of an individual’s culture may see psychopathology when a behavior or experience may actually be a normal variation of the client’s culture, such as a Native American who hears a dead relative’s voice while grieving. Some symptom clusters are uniquely associated with certain cultures, such as an “ataque de nervios” (nervous attack) in the His- panic population (APA, 2000). In clients with de- pression, biological symptoms (e.g., sleep and ap- petite disturbances) may tend to be universal, whereas psychological symptoms have been shown to vary by culture. Members of certain groups may be more likely to present with somatic complaints. Figure 3-1 Homelessness is a severe social stressor. Culture-specifi c rating scales may therefore be

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helpful in assessing clients from diverse back- ent mental illnesses (with the African Americans grounds (Kinzie & Manson, 1987). more likely diagnosed with pervasive illnesses Culturally competent assessment also re- such as schizophrenia) point to continued preju- quires sensitivity to the process of assessment. dices within our healthcare system (Blow, Zeber, The client’s comfort level in regard to disclosing McCarthy, Valenstein, Gillon, & Bingham, 2004; private issues with unfamiliar people, having Neighbors, Trierweiler, Ford, & Muroff, 2003). physical closeness with unfamiliar people, involv- The fi rst step toward culturally sensitive practice ing family in the assessment process, and being is healthcare workers’ examination of their preju- addressed by fi rst name varies among age, socio- dices regarding other cultures and the effect that economic, and ethnic groups. Because of a his- their own culture has on their work. tory of negative experiences that certain groups such as Native Americans have had with main- Spirituality and Values stream medicine, members of these groups may Spirituality is an often neglected aspect of be reluctant to participate in the traditional West- assessment, especially in the acute care setting. ern assessment or treatment process (Vedantam, Nursing as a profession may have overlooked 2005). The presence of language barriers must be the spiritual aspects of assessment and care as it carefully assessed, because clients who may ap- has struggled to assert itself as a research-based pear to speak English adequately may be more profession (Govier, 2000). However, a client’s comfortable in their native tongue, especially lack of or sense of spirituality may have a tre- when discussing emotional issues. Ideally, inter- mendous impact on illness and treatment. The preters are familiar with medical terminology belief in a divine plan and a benevolent God is and are not members of the client’s own family comforting to many clients (Carson & Arnold, (to decrease communication problems and pro- 1996). Some clients feel that spirituality de- tect the client’s privacy). creases their sense of aloneness and despair. The effi cacy of different treatment modalities Spirituality and religiosity may deter suicide and and beliefs regarding the etiology and treatment violence. Conversely, some clients may become of mental illness may also vary among cultures angry with God for having caused their suffer- and must be considered when developing a treat- ing and may lose faith. Spiritual aspects of treat- ment plan. Among some people in certain cul- ment, such as the concept of a higher power in tures, mental illness may be viewed as a punish- the 12-step treatment program for alcohol and ment for past wrong-doing or as a result of a drug abuse, may engage spiritually minded curse; convincing clients with these beliefs that clients but deter those who are not religious. A Western medication will treat the illness can be diagnostic category of religious or spiritual challenging. Enlisting the help of community el- problems has been included in the Diagnostic ders or traditional healers, instead of arguing and Statistical Manual of Mental Disorders, 4th Edi- against the beliefs, may be helpful in this regard tion, Text Revision (DSM-IV-TR) (APA, 2000). (Vedantam, 2005). The role of the extended fam- Religion is a way of expressing spirituality ily and community in assisting with the treatment through an organized framework and through of the mentally ill also differs among groups, rituals. Clients should be asked about religion and which will also need to be considered when delin- whether or not they would like clergy involved in eating care. In some cultures, the mentally ill tend their treatment. Religiosity is correlated with rela- to be ostracized whereas in others the community tively high levels of social support, decreased rates takes pride in caring for these individuals. Even of depression, high levels of cooperation, and high the effi cacy, dosing, and side effects of psychotro- levels of cognitive functioning (Koenig, 2007; pic medication may differ signifi cantly among Koenig, George, & Titus, 2004). In adolescents, re- ethnic groups (Vedantam, 2005). ligiosity is correlated with lower levels of drug Although it is important to have a working abuse, violence, and behavioral problems (Barnes, knowledge of general differences among cultures, Plotnikoff, Fox, & Pendelton, 2000). it is essential that the nurse avoid stereotyping in- We often equate religion with spirituality; dividual clients on the basis of ethnic, racial, or however, spirituality is a much broader concept. social group membership. Data supporting that Although atheists do not believe in God and ag- African Americans and whites presenting with nostics are unsure of God’s existence, it cannot be comparable symptoms are diagnosed with differ- assumed that spirituality is absent in members of

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these groups. Govier (2000) did an extensive lit- Conversely, maladaptive coping mechanisms erature search and determined that an explora- are behaviors that ultimately interfere with the cli- tion of reason, refl ection, relationships, and res- ent’s ability to confront the stressor, may be harm- toration were other important components of ful, and usually produce additional stress. Unfortu- spirituality that should be assessed. Reason and nately, they are “tried and true” mechanisms; the refl ection refer to the client’s sources of motiva- client has successfully used them in the past to tion and strength, and the client’s ability to take maintain emotional stability in the short-term. time to refl ect on the meaning of his or her life or Consequently, clients tend to rely on these coping situation. Relationships refer to the client’s sense mechanisms to deal with future stressors. Such be- of connectedness to others and to the environ- haviors include alcohol and drug abuse, overeating, ment. Restoration refers to the ability of the spir- inappropriate anger, and social withdrawal. itual dimension to positively infl uence the physi- Discerning the client’s characteristic pattern of cal aspect of care. On the other hand, spiritual coping—whether it is adaptive or maladaptive— distress (which can be the outcome of certain ad- helps the nurse to predict how the client may react verse life events) can precipitate or aggravate a during a current stressor. It is often helpful to spend course of illness. time uncovering and encouraging the use of the Nurses who are not in touch with their own adaptive coping mechanisms that have been suc- spirituality will tend to shy away from including cessfully used by the client in the past, because cli- an in-depth spiritual assessment of clients, so ents in current crisis are often feeling overwhelmed self-awareness is the fi rst step toward performing and may need prompting to remember the skills in a competent spiritual assessment. Observing for their arsenal. the presence of a bible, cross, or star of David may also give clues to the client’s spirituality. Be- Content of the Psychiatric Nursing ing present with the client, using active listening Interview: Mental Status Examination skills, being nonjudgmental, and taking care not to impose one’s personal beliefs onto the client Whereas the biopsychosocial history is a record of are essential skills in addressing a client’s spiri- the client’s entire lifetime, the mental status ex- tual side. amination is an evaluation of the client’s present state. Behavior and general appearance, mood and Critical Thinking Questions What kinds of challenges affect, speech, thought process and content, per- would you expect when working with a client whose cul- ceptual disturbances, impulse control, cognition, tural or spiritual background differs from yours? What knowledge, judgment, and insight are assessed. Al- would you do to overcome potential diffi culties? though it is termed an “examination,” this assess- ment guideline requires little direct questioning Coping Skills beyond what is required for taking a biopsychoso- Coping skills are mechanisms people use to cial history; most pertinent information is gleaned manage internal and external stressors. Coping from the interview process and content. behaviors can enable an individual to alter a stress- The acronym BEST PICK can assist in the re- ful situation by controlling, or at least minimizing, call of the main elements of the mental status ex- the stress resulting from the situation. Clients with amination: Behavior and general appearance; chronic psychiatric or life-threatening medical ill- Emotions: mood and affect; Speech; Thought ness may be unable to alter their condition, but can content and process; Perceptual disturbances; attempt to control the stress and minimize its Impulse control; Cognition and sensorium; and effect on their lives. A client in this situation may Knowledge, insight, and judgment. reveal several behavioral signs. They may seek more information about their illness and treat- Behavior and General Appearance ment options. These clients may participate in self- Note the client’s body frame, posture, dress, care and reach out to others, including healthcare grooming, and age-appropriateness of appear- professionals, family members, and friends. They ance. Some common adjectives used to describe may also attend support groups and express their the client’s general appearance include disheveled, feelings about self-concept, body image, and phys- well-groomed, heavily made-up, younger or older ical function. They may practice deep breathing looking than biologic age, tensely postured, under- relaxation exercises. or overweight, and casually dressed.

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In terms of behavior, assess the client’s words or themes), aphasia (diffi culties in under- gait, activity level, gestures, mannerisms, and standing or producing speech), and other disor- psychomotor activity. Manic clients may be agi- ders or oddities of speech. tated and unable to sit still, whereas clients with schizophrenia may exhibit bizarre postures or Thought Content psychomotor retardation. Observe for the rare The psychiatric nurse should note any ab- symptoms of echopraxia (a mimicking of the in- normalities in the client’s thought content. Ob- terviewer’s behavior), catatonia (statue-like im- sessions are intrusive thoughts or ideas that the mobility), and waxy fl exibility (when limbs can client recognizes as “crazy” but acts in accordance be moved by the interviewer into positions that with anyway (e.g., compulsive hand washing the client then maintains). Attempt to differenti- from an obsessive fear of germs). Hypochondria- ate between movement disturbances secondary sis is an obsession with physical concerns that do to mental illness and those resulting from medi- not exist in reality. cation side effects. Some antipsychotic medica- Delusions are convictions that have no basis tions may cause akathisia (motor restlessness), in reality. Delusions may be paranoid, grandiose, dystonia (stiffness), or dyskinesia (involuntary somatic (involving bodily concerns), erotic, nihil- muscle movement). istic (involving death or destruction), guilty, bi- The psychiatric nurse should always evaluate zarre, or referential (believing that benign envi- how the client relates to the interviewer and to the ronmental occurrences relate to or have special interviewing process. Is the client cooperative or meaning for the client). The degree of congru- uncooperative, bored, angry, or fl irtatious? ence between the client’s mood and the type of delusion experienced should be noted. Delusional Emotions: Mood and Affect content is occasionally revealed spontaneously The client’s mood is the pervasive subjective during the psychiatric interview. For example, a emotional state, and the visible expression of this client may ask the nurse to help him to hide from state is termed the affect. Observe the depth, a Mafi a hit man. Conversely, the nurse should be range, and fl uctuation of emotional expression aware that a paranoid client may be guarded in during the interview. Ask the client directly about his or her discussion of delusions secondary to his or her mood if the information is not offered pervasive lack of trust. In most cases, clients have spontaneously. Both mood and affect can be de- little insight that their thoughts are delusional, scribed as euthymic (normal), labile (rapidly and do not label them as such. The validity of de- changing from one mood state to another), de- lusions should not be questioned by the inter- pressed, irritable, anxious, angry, euphoric (exces- viewer; such questioning is ineffective in chang- sively happy), frightened, or empty. Variability in ing the client’s beliefs and often causes alienation the client’s affect should be noted, ranging from and anger (Sadock et al., 2003). fl at (no variability) to labile (rapid fl uctuation in Assessment of suicidal and homicidal affect). It is important to note congruity or in- thoughts is a priority in all evaluations of thought congruity of mood and affect. For example, some content. Suicidal thoughts are the client’s desires to depressed clients look depressed, whereas others kill or harm him- or herself, and homicidal who are depressed appear euthymic. thoughts are the client’s desires to kill or harm

Speech Clinical Example The psychiatric nurse must observe the rate, Laura is a 26-year-old female hospitalized with an acute exacerbation of amount, style, and tone of speech the client uses chronic paranoid schizophrenia. After the clients watched a televised news during the interview. Speech may range from segment about Jerusalem, Laura was overheard discussing with the other pressured to hesitant, loud to inaudible, sponta- clients her need to go on a pilgrimage to Jerusalem. Laura verbalized that neous to nonspontaneous, slurred to clear, and one particular newscaster was speaking directly to her during the show, monotonous to dramatic. The client may be de- which is how she knew that she needed to go there. After Laura was acciden- scribed as talkative or taciturn, depending upon tally bumped into by her hospital roommate later that day, Laura told her the quantity of speech. Observe for evidence of nurse that she then realized that the roommate was determined to join dysarthria (physical diffi culty in vocalizing), her in the pilgrimage. The nurse recognized these interchanges as referen- echolalia (the repetition of the interviewer’s tial delusions, active symptoms of Laura’s schizophrenia. words), perseveration (the repetition of the same

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others. Contrary to popular belief, discussing tween objects such as a chair and table. Concrete these feelings with a client does not increase, and thought is common in clients with schizophrenic may lower, the likelihood of the client’s acting on disorders. A concrete thought process is not path- them. Direct questioning is essential. Questions ological when exhibited by children, however, regarding suicidal and homicidal thoughts should who developmentally may not have the capacity elicit information regarding the client’s exact plan for abstract thought until early adolescence (Sa- (including method, extent of lethality of method, dock et al., 2003). availability of the means to carry out the plan), motivation or desire to carry out the plan, steps Perceptual Disturbances already taken to complete the plan, and factors Illusions, which are common in delirium, are preventing the client from following through, misinterpretations of true stimuli. An example is such as religiosity. The presence of active suicidal when a curtain in a dark room is mistaken for a or homicidal thoughts constitutes a psychiatric person. Hallucinations are defi ned as sensations emergency, and immediate action to ensure the experienced by the client without real external safety of the client or the object of the client’s an- stimuli. A patient may not have intact reality test- ger is necessary. ing, the ability to accept evidence that these per- ceptions are not real. Clients who appear to be Thought Process talking to imaginary others or pointing at nonex- The thought process is the way in which the istent objects during the assessment are probably client thinks. It is often evinced in the client’s experiencing hallucinations or illusions. Direct speech. Loose associations are marked by an il- questioning regarding perceptual disturbances is logical, diffi cult-to-follow shifting of ideas. Tan- usually required to elicit the specifi c symptoms. gential thinking is exhibited when the client wan- Hallucinations may be auditory, visual, gustatory, ders from the subject at hand to a related one and olfactory, or tactile; clients may hear, see, taste, is unable to come back to the original topic. Loose smell, or feel things that in reality do not exist. Au- associations, tangential thought, word salad ditory hallucinations are the most common type; (completely nonsensical combination of words), the more unusual visual, gustatory, olfactory, and and neologisms (nonsensical string of sounds tactile hallucinations may indicate medical illness that are formed into made-up words) often indi- or substance intoxication or withdrawal. cate schizophrenic disorders. Hypnagogic and hypnopompic hallucina- Circumstantial thought is demonstrated by tions are false sensory perceptions that occur clients who get lost in details but eventually re- while falling asleep and while awakening from turn to the relevant topic. Thought blocking oc- sleep, respectively. Depersonalization is a percep- curs when the thinking process stops altogether tual diffi culty in which the client feels unreal, and the mind goes “blank.” Flight of ideas, as seen dead, or mechanical; derealization is the sensa- in mania, involves pressured speech with rapid tion that the outside world is unreal. Hypnagogic topic changes; the topics may be associated, but and hypnopompic hallucinations, derealization, in a strange way. For example, “I can see! The sea and depersonalization are considered within the is washing away the shells.” Confabulation, often normal range of experience and are not consid- indicating dementia, is a fabrication of informa- ered pathologic unless they cause undue distress tion to fi ll in for memory gaps. For example, a or problems with daily functioning. client may give an elaborate but untrue story about how he or she spent the day. Impulse Control A client with a concrete thought process as op- Impulse control is the ability to delay, modu- posed to an abstract thought process is only able to late, or inhibit the expression of behaviors and understand conversations literally. For example, a feelings. Clues to the client’s ability to control his client who is asked what brought him or her to or her impulses are found in the content and pro- the hospital and responds, “an ambulance,” is cess of the general interview. A client who de- manifesting concrete thinking. A client’s ability scribes a recent history of binge drinking and in- to think abstractly may be ascertained by assess- discriminate sexual contacts has poor impulse ing the client’s interpretation of a proverb such as control. A person who storms out of an interview “people in glass houses should not throw stones” when diffi cult topics are broached also evinces or the client’s ability to describe similarities be- poor impulse control. Assessing the client’s ability

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to control impulses is an integral part of deter- edge of and insight into his illness and demon- mining potential for acting on suicidal and vio- strates poor judgment in regard to treatment. A lent thoughts. client’s judgment may be assessed by evaluating the answer to a hypothetical question such as: Cognition and Sensorium “What would you do if you found a stamped, ad- Level of consciousness, orientation, concen- dressed envelope in the street?” tration, and memory are especially important to determine when assessing clients with coexisting Critical Thinking Questions What kind of informa- medical problems or those who reveal symptoms tion gathered in the mental status examination would of dementia during the interview. During the psy- prompt you to take immediate action? Specifi cally, chiatric interview, clients provide many clues to what action would you take? their sensorium. A client with an altered level of consciousness during the interview demonstrates The Process of the Psychiatric Nursing a fl uctuating ability to maintain awareness of the environment. Orientation is assessed by simply Interview asking the client additional questions regarding The psychiatric nurse must pay attention to both full name, current location, date, and time. the content of the client’s words and the process A client’s memory and concentration are de- of communication. How the client interacts with termined by the ability to answer questions re- the nurse and the behaviors the client exhibits garding psychiatric history. Concentration may during the interview often provide important in- also be assessed by asking the client to count back- formation concerning the client’s symptomatol- ward from 100 by 7s (100, 93, 86 . . .), and memory ogy and ability to relate to others. is tested by asking the client to remember three The interviewing process varies, ranging from objects immediately and to recall them after casually talking with clients while, at the same 5 minutes. Be aware that clients may have impair- time, assisting them with activities of daily living, ments in remote, recent past, recent, and immedi- to utilizing a standardized rating scale. Different ate memory. The Mini-Mental State Examination methods may yield different information. (MMSE) effi ciently and objectively measures cog- nition (Folstein, Folstein, & McHugh, 1975). The Phases of the Interview psychiatrist, psychologist, or advanced practice An interview consists of a beginning, middle, nurse typically performs this examination. and termination phase. In the initial moments of The client’s intellectual functioning (below the interview, the nurse should begin to develop a average, average, superior) may be estimated rapport with the client and to engage the client in from the interview process as well. the meeting. Establishing a good rapport with a client is not simple; the nurse must put the client at Knowledge, Insight, and Judgment ease, empathize with the client’s suffering (i.e., un- Knowledge, insight, and judgment are related derstand how the client feels in a particular situa- concepts usually ascertained while taking the cli- tion by mentally putting oneself in the client’s ent’s history and while observing and discussing place), listen compassionately, become the client’s the client’s actions in social situations and in deal- ally, and instill trust in the client of the nurse’s ex- ing with mental illness. Judgment is the capacity pertise. The nurse must clarify the purpose of the to identify possible courses of action, anticipate meeting, which is to gain an understanding of their consequences, and choose the appropriate the client’s problems and to determine the best way behavior. Insight refers to the extent of the client’s to help. The client should be informed about the awareness of illness and maladaptive behaviors. A healthcare setting and the interviewer’s credentials, client who tells the interviewer of reuniting with and the rules of confi dentiality should be dis- a physically abusive spouse because she feels that cussed; these are requisite to making the client feel the spouse will change demonstrates poor judg- comfortable enough to share information. ment and little insight. A client who is admitted During the middle phase of the interview, to the hospital for the third time because of non- data are collected and processed. The nurse ob- compliance with antipsychotic medication, and tains information from and gives information to who states that he stopped taking the medication the client. For example, the nurse may assist the because he is not really mentally ill, lacks knowl- client in identifying ways to cope with symptoms.

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The termination phase of the interview sum- Additionally, self-disclosure reverses the marizes what has been accomplished during the interviewer-client dynamic and severs the client meeting. A tentative diagnosis and an initial care from the role of information-giver. One unique plan are formulated and shared with the client. issue of self-disclosure involves the health profes- The termination phase is also used to help the cli- sional who divulges a personal history of mental ent relax from the often emotional interaction illness. In this situation, as in others, the nurse (Kadushin, 1997). should discuss with an experienced nurse or su- pervisor and be guided by what best serves the Interviewing Techniques client’s interests. One of the most important interviewing skills One piece of information important to dis- is the ability to be silent and attentive. Nonverbal close to the client to protect the client’s rights is communication, such as nodding in understand- the interviewer’s name, title, and position. Many ing and leaning slightly toward the client, demon- students and beginning practitioners are reluctant strates caring and attentiveness. Encouraging to divulge their novice status. Clients, however, words, such as “I see” or “go on,” enable the nurse may pick up on an interviewer’s newness. Thus, to gather information without bombarding the denying that you are new in the fi eld may cause a client with questions. Allowing the client to discuss lack of trust. Clients who seem distressed by the the chief complaint during the fi rst few minutes nurse’s lack of experience should be encouraged of the interview is often an effective strategy to in- to discuss this with the nurse and may be referred duce the client to “open up.” Paraphrasing or sum- to the nurse’s supervisor for reassurance if neces- marizing the content and feelings related during sary. Psychiatric clients who have had previous the interview demonstrates that the nurse under- experience with new nurses and students often stands what the client has said and helps both the come to expect this as the norm; certain clients interviewer and the client to process an abundance actually take pride in “training” new nurses. of information. The nurse may need to ask ques- tions for clarifi cation to avoid jumping to conclu- Critical Thinking Questions What kind of personal sions about nebulous communications. Gentle information would be appropriate to share with a non- transition statements such as, “What you are tell- psychotic client on the fi rst interview? How and in ing me about is important; however, there is one what context would you disclose this information? more important thing that we still need to discuss,” keeps the interview on track without offending the Choosing Appropriate Questions client. Interviewing techniques must be individu- The client’s state and the subject being evalu- alized to the client’s specifi c problems and person- ated determine whether to ask open-ended or ality (Table 3-4). closed-ended questions. Open-ended questions are vague and may be answered in many different Self-Disclosure ways. The nurse may say, “Tell me about your prob- Revealing personal information about one- lem.” Open-ended questions are most helpful in self is a controversial technique that requires obtaining a broad range of information from nursing experience, insight, and sophistication clients without thought disorders. Closed-ended on the part of the interviewer. The nurse should questions elicit specifi c and concise information. share personal information with a client only if, Disorganized clients who are unable to tolerate a after careful evaluation, the nurse believes that long interview usually need to be guided by closed- this sharing would benefi t the client and improve ended questions when giving information. Some treatment. The nurse should never disclose per- topics of discussion, such as suicidal thoughts, lend sonal information for selfi sh reasons. themselves to direct questioning; clients who are given more freedom to answer may skirt the issue Clinical Example or provide incomplete information. Questions A client is going through a bad breakup of a relationship. The nurse may typically become more specifi c or closed-ended as feel tempted to tell the client of a similar experience (e.g., “I know how you the interview progresses (Sadock et al., 2003). feel. My boyfriend and I just split up.”). The nurse may feel good revealing Certain types of questions should be avoid- this; however, a client in acute distress may feel that the nurse is not un- ed when evaluating the client, because they may derstanding his or her unique feelings and circumstances. taint the information elicited. Leading ques- tions such as, “You do not abuse street drugs, do

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Table 3-4 Therapeutic Versus Nontherapeutic Interviewing Techniques

Goal Therapeutic Techniques and Examples Nontherapeutic Techniques and Examples To engage the client Offering self: “I will stay here with you for a Giving false reassurance: “Don’t worry; in treatment while.” everything will be fine.” Suggested collaboration: “Let’s work together Using platitudes: “Keep your chin up; to see if we can identify when your problems tomorrow is another day.” began.” To get the client to Judiciously using silence. Asking questions that yield only “yes” or “no” open up and share Actively listening by nodding and leaning toward answers. information the client. Asking incessant closed-ended questions, Using encouraging verbalizations such as “yes” so that the conversation seems like an and “I understand.” interrogation. Offering general leads such as “please continue” or “I am interested in hearing more about that.” To convey to the Summarizing the content. Using premature interpretations that deny client that you Restating content: the client’s feelings: “You’re not really angry understand Client: “I am so depressed that I cannot even eat.” with your mother; you’re just looking for Nurse: “So your depression has caused you to attention.” lose your appetite.” Inappropriately using self-disclosure: “I know Reflecting on process: “You seem anxious.“ “It just how you feel, because my boyfriend just seems difficult for you to talk about this.” broke up with me, too.” To get the client Reflecting client’s questions back to him or her: Overtly agreeing or disagreeing with the more actively Client: “What should I tell people at work about client: “What you did was definitely the right involved in my hospitalization?” (or wrong) thing to do.” treatment Nurse: “What are you thinking about telling Giving advice: “I think that you should . . .” them?” Encouraging comparison: “What have you done in the past when faced with such a difficult situation?” Encouraging decision making: “What will you do the next time that you find yourself in a similar situation?” To explore a topic in Exploring: “Could you tell me more about that Bombarding the client with multiple closed- more detail issue?” ended questions on a topic. Focusing: “Let’s go back and discuss that topic further.” To diffuse a client’s Agreeing with the grain of truth in the client’s Denying the client’s reality: nonpsychotic complaint: Client: “I hate this hospital. It’s like a jail.” anger Client: “I hate this hospital. It’s like a jail.” Nurse: “You know that this is not a jail.” Nurse: “I can see how you would feel that way, with all of the rules and the locked door. Let’s talk about how you can be more comfortable here.” To help the client Limit-setting: “I will not be able to continue Punishing the client: “You are going to have control aggressive to talk with you if you continue to act in a to stay in your room for 1 hour because you behavior threatening manner.” cursed at me” (choosing an arbitrary time Giving positive reinforcement for calm behavior. period, unrelated to the client’s behavior). Decreasing stimuli: Placing the client in a quiet area until he or she is calmer. To clarify Asking for clarification: “Could you explain that Jumping to conclusions about the meaning information to me again?” “Let’s see if I have this straight.” of a client’s statement, instead of seeking Placing events in sequence: “Did you start to drink clarification. alcohol before or after becoming depressed?” To determine causes Nonjudgmentally exploring: “What is it that gets Asking confrontational “why” questions: “Why of problems or in the way of your getting up to make it to work are you unable to get to work on time?” behaviors on time?”

continues

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Table 3-4 Therapeutic Versus Nontherapeutic Interviewing Techniques, continued

Goal Therapeutic Techniques and Examples Nontherapeutic Techniques and Examples To effectively Focusing on the feeling content of delusions: Directly challenging a client’s belief system: address delusional Client: “People are trying to kill me!” Client: “Laser beams are irradiating me!” content Nurse: “You must be very frightened.” Nurse: “There is no way that laser beams are being sent through you—that’s impossible.” To move to another Transitioning gently: “What you are saying is Rejecting a client’s topic or abruptly changing topic of discussion very important, and I want to give it proper the subject: “It’s not necessary to go attention when we have more time. Right now, into that right now. Let’s talk about your however, we need to move on.” hallucinations instead.”

you?” steer the client to answer in a certain way. convey acceptance and empathy helps the client Questions beginning with why may make the to feel comfortable in sharing information that is client become defensive. For example, “Why did of a sensitive nature. The nurse’s interest and en- you not follow your physician’s instructions thusiasm may help the client to overlook small and take your medication?” is more confronta- interviewing errors and inexperience (Sadock et tional than “Tell me more about your decision al., 2003). The nurse’s ability to be genuine is also to stop taking medication.” Questions leading important, because clients usually sense when to yes or no answers such as, “Do you drink al- others are acting unlike their true personalities. cohol?” may yield incomplete data, as opposed For example, the nurse should not attempt to to an open-ended question, such as, “Describe bond with an inner-city adolescent by using un- your alcohol use.” familiar slang. The nurse’s culture, race, age, religion, gen- Client-Related Factors Infl uencing der, socioeconomic status, and intellect necessar- the Interview ily affect the interview process. A nurse must not A client may provide unreliable information avoid issues that are important to the client but during the interview for several reasons. Symp- that are diffi cult for the nurse because of personal toms of mental illness such as delusions, disorga- background. For example, a nurse for whom spir- nized thought, or disorganized speech may inter- ituality is unimportant must not ignore the cli- fere with communication and alter the client’s ent’s spirituality. sense of reality. The client’s lack of insight may also lead to an altered perception of reality. For Transference example, an alcoholic may tell the nurse that he Transference is traditionally defi ned as a cli- or she only drinks “socially.” Some clients may ent’s unrealistic and often inappropriate feelings, purposely distort or provide false information thoughts, and behaviors toward the therapist. (e.g., an undocumented alien who feigns citizen- Transference in this traditional sense is an uncon- ship or a client with antisocial personality disor- scious displacement of attitudes originally held der who denies a criminal history). A client who toward other signifi cant persons in the client’s life, is poorly motivated for treatment (e.g., an invol- especially from early childhood, onto the health- untary client) often resists giving information. care professional (Goldstein, 1995). The concept of transference includes an appreciation for the Clinician-Related Factors Infl uencing role that the reality of the therapeutic relationship the Interview plays in determining the client’s response to treat- The nurse’s level of skill affects the fl ow of the ment and attitude toward the healthcare worker. interview and the information obtained. Inter- For example, a minority client who has been the viewing skills are related to the nurse’s degree of victim of prejudice may be appropriately appre- psychiatric experience, use of intuition or “gut hensive about disclosing information to a thera- feeling,” critical thinking abilities, personality, pist with the same ethnic background as his or her and communication style. The nurse’s ability to oppressors.

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Depending upon the client, the mental with the interviewer (e.g., tell the interviewer ex- health professional, and the specifi c relationship actly what the interviewer wants to hear) or overly between the two, the client’s reactions toward oppositional (e.g., assert that the professional has the professional comprise degrees of reality and “no right” to ask such personal questions). For the fantasy. Reality reactions are more likely to nurse, the power disparity may cause feelings of occur with healthier clients whereas uncon- omnipotence and fantasies of being able to “save” scious transference from displacement of prior the client. The nurse may fail to involve the client relationships predominantly occurs in psychotic in the treatment plan and may feel anger toward clients. Nurses who actively participate in the noncompliant clients as well. interview process correlate with more reality- based transference, because clients see these Resistance nurses as real people rather than blank screens Resistance refers to anything that impedes the onto which fantasies may be projected (Gold- progress of the interview or treatment. A client’s re- stein, 1995). sistance is often self-protective, and in many cases reticence increases when the client is confronted Countertransference directly. During the initial interview, the client The healthcare professional’s feelings and re- genuinely may be too paranoid, disorganized, de- actions toward the client are known as counter- spondent, or agitated to respond to all the ques- transference. Countertransference can be viewed tions. Confronting this resistance by asking the similarly on a reality-fantasy continuum. Woods client why he or she is not being “up-front” with the and Hollis (2000) believe that workers displace interviewer may cause the client to retreat further. feelings, attitudes, and fantasies onto some clients Temporarily changing the subject when a client more than others, depending on the workers’ becomes extremely angry or upset may enable the particular life experiences. client to continue with the interview. Validating the Vannicelli (1992) has identifi ed the following client’s feelings that underlie the resistance often ef- indicators of the presence of countertransference: fectively encourages the client to speak. For exam- inappropriate emotional responses toward the ple, a reluctant client is more likely to self-disclose if client, feelings of exhaustion, stereotyped or fi xed the nurse agrees that it must be scary to trust a responses regardless of what the client is saying, virtual stranger with personal information. exaggerated emotional responses, impulses to treat the client in a special way, and extreme over- Interview Duration or underinvolvement. Education, supervision, The duration of the evaluation interview and consultation with colleagues are essential for depends on the purpose of the evaluation, the the nurse to use the countertransference produc- client’s state, and the nurse’s availability. The tively. Appropriately analyzed, countertransfer- ence may offer important clues to a client’s diag- Clinical Example nosis or symptoms. For example, a nurse’s feelings Leo is a 15-year-old male admitted to a residential treatment center for the of extreme anger during an interview may iden- treatment of oppositional defiant disorder. Immediately upon his arrival to tify the client’s hidden rage. the unit, the admitting nurse sat down with Leo to complete a four-page nursing assessment form. When the rest of the residents lined up to go to the Power Disparity cafeteria for dinner, Leo promptly got up to join them. The nurse shouted at One important source of transference and Leo to sit back down because the assessment was not yet complete and he countertransference is the power disparity be- had not asked for permission to join the group. Leo cursed at the nurse and tween the interview participants. The interviewer stated that he was hungry. The nurse shouted back to Leo that she—and not (the nurse) assumes the responsibility for moving Leo—was in charge of the unit, and that if he “kept it up” she would ban him the interaction forward to achieve a goal, while the from the cafeteria for the rest of the week. The supervisor arrived at the client passively answers questions. This situation scene and quickly recognized that a power struggle had developed between often results in a transference, which for the client the nurse and the new resident, who were demonstrating countertransfer- represents a repetition of feelings and reactions ence and transference (respectively). The supervisor asked another nurse to from past experiences with authority fi gures. De- go over the rule book with Leo and to inform him that food would soon be pending upon the client’s history and current brought to the unit for him, while the supervisor discussed the problematic symptoms, the client may be overly compliant transaction privately with the admitting nurse.

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interview should be relatively brief (10 to 15 min- nesses. Neuropsychological testing is useful in utes) if the client is acutely ill and unable to toler- detecting subtle cognitive defects in clients who ate much contact and exploration. The interview are not obviously demented or brain-damaged. may be spread out over several short interactions, Psychological and neuropsychological tests are and the nurse may need to sit on the fl oor or even usually performed by experts in the fi eld or spe- stand if the client’s state requires it. Focused eval- cially trained nurses/mental health profession- uations, such as those evaluating a client for entry als. At minimum, nurses should be suffi ciently into an incest survivor group, are usually shorter familiar with the different tests to be able to than a broad evaluation interview because of the glean meaningful information about a client limited content. If an interview is abbreviated as a from reading the testing reports. Nurses must result of the nurse’s workload, the nurse must re- know enough to be able to recommend that cer- turn at a later time or delegate further interview- tain tests be performed. ing tasks to a colleague. Increasingly, nurses utilize standardized rat- ing scales such as those used during the assess- Environmental Issues ment process. Rating scales that are administered Uncomfortable furniture, air temperature, by trained healthcare professionals provide ob- and interruptions such as a ringing phone or jective baseline data of a client’s symptoms that beeper may impair the fl ow of an interview. A can be compared to later scores to evaluate peaceful and comfortable environment enhances the effi cacy of treatment. This is important given the interviewing process. The interview environ- the current emphasis on quality assessment, cost- ment should be private enough so that confi den- effectiveness, and managed care. Despite the tiality is not compromised. At the same time, the trend toward using standardized tools for data environment in which the interview takes place collection, this mode of assessment cannot sub- should also ensure the nurse’s safety; leaving the stitute for the nurse-client interview. door ajar and positioning oneself near the door Some rating scales were designed for clients, of the room will usually conserve privacy while and not professionals, to complete. Certain self- allowing for safe egress should a client become rating scales such as the Beck Depression Inven- aggressive. Many settings have safety measures tory yield reliable and valid data that can assist such as emergency buzzers and overhead paging professionals in the diagnosis of mental illness or systems by which other workers can be called in to gauge treatment progress. Other self-rating to assist in a crisis situation. systems are less precise but are useful for the client’s self-monitoring of illness symptoms and Collateral History coping skills. A nurse and his or her client can If a client is deemed an unreliable historian, even design their own rating scale for the client additional history should be obtained from family, based on the client’s specifi c illness symptoms, friends, colleagues, and mental health professionals for use in relapse prevention. See Table 3-5 for who have had previous contact with the client; this commonly performed psychological tests, in- collateral history may be obtained only with the cli- cluding rating scales. ent’s consent, unless it is an emergency. Those ac- companying the client to the evaluation interview Physical Assessment should be interviewed at that time, if possible. The client may feel more or less comfortable being in- The term mental disorder implies a distinction terviewed simultaneously with a signifi cant other, between mental and physical disorders. In actual- and the nurse should follow the client’s lead. Clients ity, there is much “physical” in “mental” and much should also be allowed time alone with the inter- “mental” in “physical” disorders (APA, 2000). viewer; this gives them privacy to disclose impor- Some clients who present primarily with psychi- tant information they may not be willing to discuss atric symptoms may be suffering from an under- in the presence of others. lying medical illness, such as hypothyroidism or acute intermittent porphyria. As the population Psychological Testing ages, more cases of acquired immunodefi ciency syndrome (AIDS) appear, and as the incidences Psychological testing involves evaluation tools of substance abuse and polypharmacy increase, that objectively measure personality, intelli- mental disorders resulting from general medical gence, or symptomatology of specifi c mental ill- conditions have become more prevalent. The

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Table 3-5 Commonly Performed Psychological Tests and Rating Scales

Name of Test Purpose of Test Description of Test Wechsler Adult Intelligence Intelligence test This test includes six verbal and five performance Scale (WAIS) subtests, yielding a verbal intelligence quotient (IQ), a performance IQ, and a full-scale IQ. It is the most widely used IQ test. Minnesota Multiphasic Personality assessment This is a self-report inventory of over 500 yes Personality Inventory or no questions, the results of which are (MMPI) scores on 10 different scales (e.g., depression scale, paranoia scale). The pattern of scores is interpreted by the tester by comparing the scores and subscores against standardized data. Rorschach Test Projective personality assessment Clients are shown inkblots and asked to describe what they see. Clients project their needs, fantasies, and thoughts into the inkblots because of their ambiguity. This test is very difficult to analyze. Substance Abuse Subtle To identify people who have a high A 15-minute questionnaire, including face valid Screening Inventory (SASSI) probability of substance use items as well as subtle items that do not address disorders, even when they are substance misuse in a direct or apparent unlikely to admit to the problem manner. outright. There is one version of the test for adults, and another for adolescents. Abnormal Involuntary To test for psychomotor side A 12-item inventory performed by trained Movement Scale (AIMS) effects of psychotropic evaluators who rate the client’s involuntary medication muscular movements on a scale of 0 to 4. Hamilton Depression Rating To test for severity of depression in A 21- or 17-item inventory performed by trained Scale (HAM-D) clients already diagnosed with an evaluators who rate physical and psychological affective disorder symptoms of depression on a scale of 0 to 4. Beck Depression Inventory To measure attitude and symptoms A 21-item inventory performed either by a (BDI) that are characteristic of trained professional or by the client, who rates depression depressive symptoms and attitudes on a scale of 0 to 3. Brief Psychiatric Rating Scale To assess psychopathology in A 16-item inventory of a broad range of (BPRS) clients with, or suspected of psychiatric symptoms, scored by a trained having, schizophrenia or other professional using a 7-point Likert scale. psychotic illness Mini-Mental State Examination To screen for cognitive impairment A nine-item structured clinician-rated interview (MMSE) caused by dementia scale incorporating pencil-and-paper tasks.

term organic is used in clinical practice to refer to Clinical Example these illnesses. Kay, a 52-year-old woman, was admitted to the psychiatric unit from the A medical workup may be completed to rule emergency room. She presented primarily with agitation. She seemed to out organic illness. The medical workup also en- be hallucinating, speaking to people who were not there. On closer ex- sures that the client is well enough to tolerate psy- amination, Kay was delirious with waxing and waning cognitive abilities. chopharmacologic and other psychiatric treat- She was disoriented to place and time, tachycardic, and diaphoretic. Kay ments safely. The physical examination is an was able to provide a history of hypothyroidism, which had been treated essential part of the workup that may be per- sporadically with thyroid replacement hormone. Her family provided ad- formed by the advanced practice nurse. Basic- ditional history concerning Kay’s chronic alcoholism. Kay was transferred level nurses assess the client’s vital signs, teach the to a medical unit where she was placed on a librium alcohol detoxification client about the examination, and reassure him protocol, and her thyroid level was stabilized. Most of her presenting or her throughout the examination. Important symptoms resolved. clinical laboratory tests include serum and urine

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drug screens; thyroid, liver, and kidney function Nursing diagnoses were originally catego- tests; complete blood counts; and sexually trans- rized by the North American Nursing Diagnosis mitted disease screening. Serum tests are also Association (NANDA) in 1986, and were last re- used to evaluate the levels of psychotropic medi- vised for 2007–2008 (www.nanda.org). Nursing cations in the client’s blood. A low lithium level, diagnoses may relate to actual problems, risks for for example, may precipitate a manic episode. A problems, or wellness issues. A nursing diagnosis number of medical illnesses present with psychi- is a concisely worded statement that includes the atric symptoms, and specifi c diagnostic tests are diagnostic label/defi nition, related factors, and used to detect them (Table 3-6). defi ning characteristics. Specialized diagnostic procedures performed One example of a nursing diagnosis is “post- on psychiatric clients include an EEG, which dis- trauma syndrome related to physical abuse, as cerns if a seizure-like basis for an illness, such as an evidenced by fl ashbacks, nightmares, and hyper- impulse control disorder, exists. In delirium, as a vigilence.” result of metabolic problems, the EEG generally Formulating nursing diagnoses is diffi cult be- shows high-voltage, slow-wave activity. Other tests cause of the array of possible human responses and including MRI, computed tomography (CT), and the causes of these responses (Regan-Kubinski, positron emission tomography (PET) identify 1995). Prioritizing these diagnoses is therefore es- space-occupying lesions and metabolic brain dis- sential. Without question, safety issues must be of orders. The tests may also identify biologic mark- primary concern (e.g., the risk for self-directed ers of mental illness; researchers have found evi- violence). Some diagnoses are addressed immedi- dence of increased brain ventricle size detected by ately, and others require long-term intervention. MRI and CT and decreased frontal cortex activity Remember that several diagnoses may be addressed detected by PET in clients with certain forms of simultaneously and that they will continue to be schizophrenia (Sadock et al., 2003). addressed in the outpatient setting (e.g., with home care, day program, psychotherapy, psychopharma- Organizing Data: Diagnosis cology). The client and family should actively par- ticipate in prioritizing the nursing diagnoses. Formulating the client’s diagnosis is an integral part of the psychiatric evaluation. During the as- Diagnostic and Statistical Manual sessment, the nurse must keep an open mind and of Mental Disorders avoid settling on a defi nitive diagnosis early in the interview. All aspects of the holistic assessment The Diagnostic and Statistical Manual of Mental must be considered. Disorders has been the primary resource used throughout the United States for classifying Nursing Diagnosis mental disorders since its original publication in 1952. More than 1,000 health professionals The American Nurses Association (ANA, 2007) analyzed scientifi c data and performed fi eld tri- states that nurses diagnose “human responses to als to test for validity and reliability of diagnos- actual or potential health problems.” The prac- tic categories, to prepare the DSM-IV (APA, tice of nurses diagnosing clients has met with 1994). In 2000, the American Psychiatric Asso- long-standing resistance. Many nurses who ciation revised parts of the text portion of the graduated prior to the inclusion of the nursing DSM-IV to include new research information diagnosis in the college curricula feel that mak- regarding associated features; culture, age, and ing a diagnosis is beyond their scope. Nurses gender features; prevalence; course; and familial who were exposed to the theoretical aspects of pattern of many of the mental disorders listed. the nursing diagnosis in school often have diffi - This new version, DSM-IV-TR, included very culty translating this knowledge into practice. few changes to the diagnostic categories; the Other professionals, notably physicians, may most notable changes in this regard were with fear that boundaries are being crossed when the tic disorders and the paraphilias, which may nurses formulate diagnoses. Clients may be now be diagnosed even if the associated behav- wary when nurses take a leadership role in their iors do not cause the person distress or impaired treatment. functioning (APA, 2000).

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Table 3-6 Physical Illnesses Presenting with Psychiatric Symptoms

Tests Used to Diagnose Physical Illness Physical Symptoms Psychiatric Symptoms Physical Illness Acquired Fever, weight loss, ataxia, Progressive dementia, HIV antibody test, CT scan, immunodeficiency incontinence, seizures, and personality changes, and MRI, lumbar puncture, syndrome (AIDS) opportunistic infections depression and blood cultures Acute intermittent Abdominal pain, fever, nausea, Depression, agitation, CBC, pulse, and Δ- porphyria vomiting, constipation, paranoia, and visual aminolevulinic acid and peripheral neuropathy, and hallucinations porphobilinogen levels paralysis Brain neoplasm Headache, vomiting, papilledema, Personality changes Lumbar puncture, skull and local finding on neurological x-ray, CT scan, and EEG examination Hepatic Hyperreflexia, ecchymosis, liver Euphoria, disinhibition, LFTs, serum albumin level, encephalopathy enlargement, and ataxia psychosis, depression and EEG Huntington’s disease Rigidity and choreoathetoid Depression and euphoria Genetic testing movements Hyperglycemia Polyuria, anorexia, nausea, Anxiety, agitation, and Fingerstick for blood vomiting, dehydration, delirium glucose and urine dipstick abdominal complaints, acetone for glucose and ketones on breath, and seizures Hyperthyroidism Sweating, diarrhea, weight loss, Nervousness, irritability, TFTs and ECG tachycardia, tremor, palpitations, pressured speech, vomiting, and heat intolerance insomnia, and psychosis Hypoglycemia Sweating, drowsiness, stupor, Anxiety, confusion, and Pulse rate and fingerstick coma, tachycardia, tremor, agitation for blood glucose restlessness, and seizures Hyponatremia Excessive thirst, polydipsia, Confusion, lethargy, and Serum electrolytes stupor, and coma personality changes Hypothyroidism Dry skin, cold intolerance, Lethargy, depression, TFTs and ECG constipation, weight gain, and personality changes, and goiter psychosis Multiple sclerosis Sudden transient motor and Anxiety, euphoria, mania, Lumbar puncture and sensory disturbances and personality changes head CT Seizure disorder Sensory distortions and aura Confusion, psychosis, EEG dissociative states, catatonia-like states, violence, and bizarre behavior Systemic lupus Fever, photosensitivity, butterfly Depression, mood changes, ANA, lupus erythematosus erythematosus rash, headache, and joint pain and psychosis test, CBC, chest x-ray Tertiary syphilis Skin lesions, arthritis, respiratory Personality changes, VDRL and lumbar puncture distress, and progressive decreased performance of cardiovascular disease activities of daily living, irritability, confusion, and psychosis Thiamine deficiency Neuropathy, cardiomyopathy, Confusion and Thiamine level nystagmus, and headache confabulation

Vitamin B12 Pallor, dizziness, peripheral Irritability, inattentiveness, Vitamin B12 level, Schilling deficiency neuropathy, and ataxia and psychosis test, and CBC

Note: HIV ϭ human immunodeficiency virus; CT ϭ computed tomography; MRI ϭ magnetic resonance imaging; CBC ϭ complete blood count; EEG ϭ electroencephalogram; LFTs ϭ liver function tests; TFTs ϭ thyroid function tests; ECG ϭ electrocardiograph; ANA ϭ antinuclear antibody test; VDRL ϭ venereal disease research laboratory test

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Psychiatric nurses must be well versed in the son him- or herself; the client is not just a “schizo- classifi cation system and terminology used in phrenic,” but a multifaceted individual who hap- the DSM-IV-TR, but only the advanced practice pens to have schizophrenia (APA, 2000). registered nurse (APRN) may use the guide to diagnose a mental disorder. To diagnose a client Multiaxial DSM-IV Diagnosis with the DSM-IV-TR, an individual must have appropriate training and experience with the sys- Diagnosing mental disorders with the DSM-IV- tem (APA, 2000). TR is not foolproof; various mental disorders have When working with the DSM-IV-TR, the overlapping symptoms, and individuals with the nurse must remember that normal reactions to same disorder may differ signifi cantly. The manual stressful events, such as the death of a loved one, provides text and decision-tree diagrams that as- are not considered mental disorders. Additionally, sist in establishing the differential diagnosis. The some phenomena, which in the mainstream DSM-IV-TR also provides guidance to diagnose would indicate a mental disorder, are not symp- clients with insuffi cient information or informa- tomatic for a mental disorder if they are culturally tion that does not fi t neatly into one category. A appropriate. For example, in certain Hispanic cul- diagnosis may be deferred, declared provisional, or tures persons may talk to their dead mother’s delineated as atypical or not otherwise specifi ed ghost. Socially unacceptable behavior, such as (NOS; APA, 2000). The diagnostic categories of crime, does not necessarily indicate a mental ill- the DSM-IV-TR often include several subtypes ness. Lastly, the nurse must remember that the as well as descriptive statements that indicate the person’s diagnosis is being classifi ed, not the per- severity and course of the illness.

CASE STUDYY Mr. C.

Psychosocial history: Mr. C., a 60-year- cian’s advice and applied for disability Mr. C. had no previous psychiatric old man, was brought to the hospital payments. He soon fell into debt, result- history. He did not use drugs or alcohol, by ambulance immediately following a ing from the lengthy waiting period for but has smoked one pack per day for suicide attempt by hanging. This hos- disability payments, family weekend 40 years. His medical history was sig- pitalization marked his fi rst contact gambling excursions to Atlantic City, nifi cant for heart disease. Mr. C. had a with the mental healthcare system. Mr. and accumulating medical bills. Mr. C., family history of hypertension and C. arrived combative and in four-point who had always been the head of house- heart disease. He reported that his restraints and presented with the chief hold in his traditional family, felt that mother suffered from postpartum de- complaint, “I just wanted to die. . . . I he had no choice but to return to work. pression after the birth of her third feel hopeless and lost.” According to He also became noncompliant with his child, which resolved without treat- the client, he had been feeling de- heart medications, began to withdraw ment. Mr. C. was the oldest of three pressed for 2 months preceding the at- from social events, had frequent argu- children in a middle class family. Mr. C. tempt and had experienced diminished ments with his wife, and experienced a met normal developmental milestones. appetite, insomnia, anhedonia, hope- reemergence of chest pain. Mr. C.’s father died when he was 14 years lessness, helplessness, and worthless- Mr. C. fi nally terminated his em- of age, after which Mr. C. was forced to ness during the 2 weeks prior to his ployment a few months later, upon re- drop out of school in order to work to suicide attempt. ceipt of disability checks. A month prior help support his family. Although Mr. The client identifi ed that his trou- to the suicide attempt, Mr. C. received C. was close with his siblings in his bles began 1 year prior, when his cardi- notifi cation from the disability offi ce youth, he fell out of touch with them af- ologist advised Mr. C. to leave a job that that he was ineligible for the entitlement ter their mother passed away. He and he had held for over 30 years because of because he had worked for those few his wife had been married for nearly his compromised physical condition months after having applied and that he 40 years at the time of the hospitaliza- following a coronary bypass operation. owed $4,000 in back pay. It was also tion. Their two grown children were liv- Although Mr. C. had not planned an around this time that his teenaged grand- ing out of state. Mr. C. was normally in early retirement, he heeded the physi- son was incarcerated for armed robbery. close contact with his children by tele-

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The multiaxial DSM-IV-TR diagnosis is divided clearly stated that the client’s primary diagnosis is into fi ve categories, or axes. on Axis II. Axis I and Axis II together contain the entire classifi cation of mental disorders, number- Axis I ing over 300 illnesses. This list of disorders is large Axis I comprises mostly clinical disorders such but incomplete because the classifi cation system as major depression, chronic schizophrenia, and constantly evolves through research. attention defi cit disorder. Specifi c diagnostic crite- ria, consisting of the signs and symptoms of the Axis III illnesses, are provided for each of these disorders. Axis III denotes the client’s physical disorders Some of these criteria must be present before a di- or medical conditions. A medical illness may be agnosis is made, and other symptoms may accom- the cause of the mental disorder (e.g., human im- pany them. The information obtained through the munodefi ciency virus [HIV] infection on Axis III interview and testing is compared with the signs with dementia secondary to HIV infection on and symptoms found in the descriptions of the Axis I), the result of the mental disorder (e.g., cir- DSM-IV-TR for specifi c disorders. rhosis on Axis III with alcohol dependence on Axis I), or unrelated to the mental disorder. Axis II Axis II includes personality disorders and Axis IV mental retardation, along with the related diag- Axis IV recognizes psychosocial and environ- nostic signs and symptoms. Axis II diagnoses are mental factors that may precipitate, result from, or deemed secondary to Axis I diagnoses, unless it is affect the treatment of mental illness. Axis IV lists

phone. He had several close friendships was cooperative with the interview for survival. Mr. C. was alert and oriented through his job and from his church, 20 minutes, after which point he stated to person, place, and time. His memo- but lately had not been socially involved that he was too tired to continue. The ry for recent history was intact, and with anyone besides immediate family. client’s mood was depressed, with a de- his concentration seemed mildly im- Although Mr. C. had never earned pressed affect that was constricted in paired. His level of intellect was deemed his high school diploma, he had a suc- range. His speech was slow, soft, and average, and he seemed to be a reliable cessful career with the local utilities nonspontaneous. Mr. C. evinced no historian. company until his recent health prob- formal thought disorder. Mr. C. denied Mr. C. rated his depression by using lems. Mr. C. verbalized a strong belief experiencing hallucinations, and there the Beck Depression Inventory, scoring that the male in the household should was no evidence of delusional thought. in the range indicative of severe depres- be the primary provider for his family He expressed ambivalence about hav- sion. The review of Mr. C.’s activities of and that the woman should tend to the ing survived his suicide attempt but daily living was signifi cant for dimin- home. Mr. C. considered himself reli- stated that he had no plan to try again ished appetite with a 20-pound weight gious, regularly attended services, and while in the hospital, because he loss as well as initial insomnia over the took comfort in his belief in God. When wanted to see if we could help him with past year. His laboratory tests were all asked about coping skills, Mr. C. re- his problems. Mr. C. stated that per- within normal limits. Mr. C.’s physical ported that in the past he talked about haps his surviving the attempt was examination was signifi cant for hyper- his problems with friends and his priest. God’s way of telling him that other tension. He reported that smoking gives him people needed him here on earth. His See Table 3-7 for the diagnostic for- some relief from anxiety. impulse control, judgment, and insight mulation for Mr. C., and Nursing Care On the mental status examination, were poor to fair, as shown by his gam- Plan: Mr. C.—Depression for the asso- Mr. C. was a well-groomed Caucasian bling, going back to work against his ciated nursing care plan. man who appeared older than his doctor’s advice, noncompliance with years. His posture was poor, and he ex- cardiac medications, impulsive suicide hibited psychomotor retardation. He attempt, and ambivalence about his

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Table 3-7 Diagnostic Formulation of Mr. C.

DSM-IV-TR Diagnosis NANDA-I Diagnosis Axis I: 296.2 Major Depressive Disorder, Single Episode Risk for suicide related to depression and stressful life Axis II: 312.31 Provisional Diagnosis: Pathological Gambling events, manifested by serious suicide attempt 799.9 Diagnosis deferred on Axis II Ineffective health maintenance related to financial difficulties Axis III: Atherosclerotic Heart Disease, Hypertension and depression, manifested by noncompliance with cardiac Axis IV: Adjustment to forced early retirement, medical medication illness, financial difficulties, family discord Imbalanced nutrition: less than body requirements related Axis V: GAF ϭ 20 (on admission to hospital) to depression, manifested by decreased appetite and weight loss Sleep deprivation related to depression, manifested by insomnia Situational low self-esteem related to medical illness, forced early retirement, and depression; manifested by inability to maintain family finances and marital discord

Note: DSM-IV-TR ϭ Diagnostic and Statistical Manual of Mental Disorders, 4th ed., Text Revision; NANDA-I/Nursing Diagnoses: Definitions and Classifications, 2007–2008; GAF ϭ global assessment of functioning

NURSING CARE PLAN Mr. C.—Depression

Expected Outcomes Interventions Evaluations • Will not make suicidal • Monitor client on a 1:1 • Evaluating for suicidal thoughts, plan, gestures observation intent, lethality, and access to means each shift • Assessing the client’s reasons to continue living • Will sleep 6–7 hours a • Teach relaxation techniques • Evaluating the client’s demonstration of night relaxation techniques, evaluating number of hours slept nightly • Will improve nutritional • Assess for likes and dislikes, en- • Monitoring for weight gain on a weekly intake couraging small, frequent meals, basis referring to a nutritionist • Will learn alternative • Assist the client in identifying • Observing for increased use of adaptive coping mechanisms coping mechanisms that have coping mechanisms worked in the past in similar situations • Will be compliant with • Teach the client about heart • Monitoring compliance with cardiac medi- treatment disease and treatment cation • Will have improved • Identify and assist in correct- • Administering Beck Depression Inventory sense of self-worth ing cognitive distortions at regular intervals • Will establish con- • Discuss possible community • Evaluating the client’s participation in a tact with community resources and support systems heart disease support group resources

Visit http://nursing.jbpub.com/book/psychiatric for additional care plans and exercises.

psychosocial and environmental events that would catastrophic, in which case they may be directly in- have a strong impact on the average person and volved in the etiology of the mental disorder that were experienced by the client in the year pre- (e.g., childhood abuse leading to PTSD). Stressors ceding the evaluation. Events occurring prior to may include negative events, such as job loss, as that time should not be included unless they are well as events ordinarily deemed positive, such

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as the birth of a child. The DSM-IV-TR categorizes ning should be done in collaboration with the these stressors into clusters that the clinician should client, family, and other members of the inter- use as evaluation guidelines. The client’s specifi c disciplinary treatment team. The therapeutic problems should be listed under Axis IV. contract is the agreement between the nurse and client to work on these mutually identifi ed prob- Axis V lems. A contract may be in written form or may Axis V indicates the client’s overall ability to be a verbal agreement. Especially in the begin- function. Using the Global Assessment of Functioning ning of treatment, the amount and type of col- (GAF) scale, the interviewer rates the client’s total laboration client and family offers may be lim- psychological, social, and occupational or academic ited; the nurse must then accept the balance of well-being on a scale of 1 to 100 (1 being virtually responsibility for treatment. Some clients ac- nonfunctional and 100 being asymptomatic with tively resist collaboration. When this is the case, superior function in all realms). Both the severity the nurse’s fi rst priority is to engage the client in of psychiatric symptoms and the degree of social, treatment by setting fi rm limits, providing posi- work, or school impairment are considered on the tive reinforcement for small steps, and persever- scale, which represents a continuum of mental ing against resistance. health and mental illness. A person’s GAF score Interventions in the nursing care plan focus on changes over time, thus the clinician must rate the improving the client’s ability to function and qual- client for the most pertinent time period (e.g., upon ity of life. Some examples of interventions available admission, upon discharge, highest level in past to the psychiatric nurse include counseling, milieu year) and identify the time frame of the rating. The therapy, self-care assistance, medication adminis- GAF score is useful when operationalizing a client’s tration, education, case management, and health progress from admission to discharge. It is also promotion. In addition, advanced practice nurses helpful in formulating a prognosis; a high premor- may implement psychotherapy, prescribe pharma- bid GAF score portends a good prognosis. cologic agents, and provide consultation. In many settings, generic or standardized Outcome Identifi cation and Planning nursing care plans and contracts for specifi c nurs- of Nursing Care ing diagnoses, medical diagnostic groups, or cli- ent problems exist. These plans are good guide- The initial nursing care plan is based on the com- lines but should be tailored to the individual prehensive assessment and attendant nursing di- client’s needs. agnoses, with consideration of the medical diag- nosis. Initial planning of care marks the fi nal phase of the psychiatric client’s evaluation. The Summary care plan consists of the nursing diagnoses or Holistic evaluation of the psychiatric client con- problem list, outcome goals, interventions used sists of assessing the client’s biopsychosocial his- to attain these outcomes, and evaluation of the tory and current mental status through the psy- interventions and their effi cacy in achieving de- chiatric nursing interview. The specifi c content sired outcomes. Outcome identifi cation is an im- and process of the interview depends upon the portant part of the nursing process; interventions nurse, the client, and the context in which the in- cannot be delineated without fi rst outlining the terview takes place. In terms of content, the bio- goals of the interventions (ANA, 2007). psychosocial history includes the client’s chief The outcome measures should be client- complaint; HPI; psychiatric history; alcohol and centered, realistic, observable, measurable, spe- substance use history; medical, family, develop- cifi c, time-limited, and mutually agreed upon by mental, social, occupational, or educational his- client and nurse. Some diagnoses lend them- tories; culture; spirituality; and coping skills. The selves to easily operationalized outcome mea- mental status examination comprises an evalua- sures, and others present some diffi culty as a tion of the client’s current behavior and appear- result of the subjective nature of the probe. For ance; emotions: mood and affect; speech; thought example, outcome measures for altered nutri- content and process; perceptual disturbances; tion are more easily quantifi ed than are mea- impulse control; cognition and sensorium; and sures for self-esteem disturbance. knowledge, insight, and judgment. The nurse In early care planning, the goal is to identify may remember these components with the acro- and explore urgent problems. Initial care plan- nym BEST PICK.

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In terms of process, the psychiatric nursing systematic listing of the offi cial codes and categories, interview consists of a beginning, middle, and a description of the multiaxial system for diagnosis, and termination phase. The primary task of the begin- diagnostic criteria for each of the disorders. It is used by psychiatrists, physicians, psychologists, registered ning phase is to develop a rapport with the client. nurses, social workers, therapists, and other mental The bulk of information sharing is done during the health workers in all clinical settings. The 2000 text middle phase. The termination phase relaxes the revision includes new research information regarding client and summarizes the meeting. Interviewing associated features; culture, age, and gender features; techniques such as nodding one’s head, refl ecting prevalence; course; and familial pattern of many of the feelings, and restating content facilitate the interac- mental disorders listed. tion; bombarding the client with questions and Barnes, L., Plotnikoff, G., Fox, K., & Pendelton, S. (2000). denying his or her feelings are detrimental to the Spirituality, religion, and pediatrics: Intersecting worlds of healing. Pediatrics, 106(4 suppl.), 1–19. interview. Transference and countertransference This article covers the clash between spirituality and (the conscious or unconscious feelings, expecta- biomedicine, and the effect of spirituality on children’s tions, beliefs, and attitudes the client and clinician health and on the provider of health services. have for one another) may also infl uence the inter- Blow, F. C., Zeber, J. E., McCarthy, J. F., Valenstein, M., view positively or negatively. Gillon, L., & Bingham, C. R. (2004). Etnicity and The DSM-IV-TR diagnosis is a multiaxial diagnostic patterns in veterans with psychoses. medical diagnosis that considers major mental ill- Social Psychiatry and Psychiatric Epidemiology, ness as well as personality, intellectual functioning, 39(10), 841–851. medical illness, psychosocial stressors, and global This study used a national database for veterans diag- functioning. The assessment data from the psychi- nosed with serious mental illness and confi rmed contin- ued ethnic disparities in diagnosing mental illness, with atric nursing interview (with consideration of the race being the demographic variable most strongly as- DSM-IV-TR diagnosis, psychological testing re- sociated with a diagnosis of schizophrenia. sults, and medical workup outcome) are used to Carson, V. B., & Arnold, E. N. (1996). Mental health formulate nursing diagnoses. These diagnoses are nursing: The nurse-patient journey. Philadelphia: prioritized with input from the client, and safety is W. B. Saunders. the primary concern. The nurse collaborates with This psychiatric nursing text focuses on the often forgot- the client in formulating the initial nursing care ten spiritual aspect of the nurse-client relationship. plan, which consists of the identifi ed problems Catherman, A. (1990). Biopsychosocial nursing as- (nursing diagnoses), projected treatment outcomes sessment: A way to enhance care plans. Journal of and interventions, and evaluation of the process. Psychosocial Nursing and Mental Health Services, 28(6), 31–35. This article advocates for the use of scientifi c data collec- Annotated References tion tools by nurses as a way of enhancing professional- American Nurses Association. (2007). Psychiatric- ism and patient care. mental health nursing: Scope and standards of Erikson, E. (1963). Childhood and society (2nd ed.). practice. Washington, DC: American Nurses Pub- New York: W. W. Norton & Company. lishing. This pioneering work regarding the evolution of person- This text outlines the ANA’s recommendations for psychiat- ality over one’s lifetime is easy to understand and apply ric nursing practice. It guides the practice of all psychiatric to practice. Development is put into historical and socio- nurses, especially those new to the fi eld. Psychiatric nurses logical perspective, and the role of the child in society is should keep up with current nursing trends by reading the also explored. latest version of the ANA’s statement. Folstein, M. F., Folstein, S. E., & McHugh, P. R. (1975). American Psychiatric Association. (1994). Diagnostic “Mini-Mental State,” a practical method for grad- and statistical manual of mental disorders (4th ing the cognitive state of patients for the clinician. ed.). Washington, DC: Author. Journal of Psychiatric Research, 12, 189–198. This is the fourth edition of the American Psychiatric This article introduced the mini-mental status examina- Association’s offi cial nomenclature of psychiatric condi- tion and scoring method. tions and disorders. Goldstein, E. G. (1995). Ego psychology and social work American Psychiatric Association. (2000). Diagnostic practice (2nd ed.). New York: Free Press. and statistical manual of mental disorders (4th ed., Although aimed at a social work audience, this text ap- text rev.). Washington, DC: Author. plies to nursing practice; both professions are attract- This is the text revision of the fourth edition of the ed to ego psychology’s engagement of the health and American Psychiatric Association’s offi cial nomenclature strengths of the client. Assessment is viewed from an ego of psychiatric conditions and disorders. It provides a psychologic vantage point, stressing both defense mech-

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anisms and the rational and problem-solving capacities predicted fewer depressive symptoms, and organized of the ego. Problems in functioning are viewed in relation religious activities predicted better physical functioning to possible coping defi cits and the fi t between inner ca- and less severe illness. pacities and environmental resources. The text’s easy-to- Koenig, H. G. (2007). Religion and depression in older understand chapter on the assessment of defense mecha- medical inpatients, American Journal of Geriatric nisms is an excellent resource. Psychiatry, 15(4), 282–291. Govier, I. (2000). Spiritual care in nursing: A system- This study examined the relationship between religious atic approach. Nursing Standard, 14(17), 32–36. characteristics of older medically ill patients with depres- This article advocates for taking a systemic approach to sion and those of medically ill nondepressed patients. assessing clients’ spiritual needs. The need for nurses Depression was less severe in patients who identifi ed a to evaluate personal spirituality before effectively as- religious affi liation and formal religious practices. sessing clients’ spiritual needs is also discussed. National Child Traumatic Stress Network (2004). Gresenz, C. R., Sturm, R., & Tang, L. (2001). Income Childhood traumatic grief educational materials. and mental health: Unraveling community and Los Angeles, CA: National Center for Child Trau- individual level relationships. Journal of Mental matic Stress. www.NCTSNet.org Health Policy and Economics, 4(4), 197–203. This is an in-depth general information guide to child- A study by the Rand Organization that examined the hood traumatic grief with information specifi c to health- relationship between mental disorder and socioeco- care providers, parents, and school personnel. It includes nomic status. The fi ndings confi rmed earlier studies that a useful reference and resource list. showed individual income to be highly correlated with Neighbors, H. W., Trierweiler, S. J., Ford, B. C., & Mur- mental health status. off, J. R. (2003). Racial differences in DSM diag- Guy, W. (1976). ECDEU Assessment Manual for Psy- nosis using a semi-structured instrument: The chopharmacology. Washington, DC: U.S. Depart- importance of clinical judgment in the diagnosis ment of Health, Education and Welfare. of African-Americans. Journal of Health and So- This is the original publication of the Abnormal Involun- cial Behavior, 44(3), 237–256. tary Movement Scale (AIMS). This article analyzed data on 665 African Americans and Kadushin, A. (1997). The social work interview: A guide white psychiatric patients and found that, even when a for human services professionals (4th ed.). New semi-structured diagnostic instrument and DSM criteria York: Columbia University Press. were used, whites were more likely than African Ameri- This book applies to the work of all mental health profes- cans to receive a diagnosis of bipolar disorder and less sionals. It contains detailed discussion of the beginning, likely to be diagnosed with schizophrenia. middle, and termination phases of the interview and of Rauter, U. K., de Nesnera, A., & Grandfi eld, S. (1997). the clinician-client relationship. A thoughtful chapter is Up in smoke? Linking patient assaults to a psychi- included regarding the use of humor and self-disclosure atric hospital’s smoking ban. Journal of Psychoso- in the therapeutic relationship. This edition includes ex- cial Nursing and Mental Health Services, 35(6), tended information on listening, nonverbal communica- 35–40. tion, use of interpreters, and interviewing involuntary This overview of the effects of smoking and smoking ces- adults and sexually abused children. sation in psychiatric clients is essential to understanding Kessler, R. C., Sonnega, A., Bromet, E., Hughes, M., & the pros and cons of the recent antismoking movement in Nelson, C. B. (1995). Posttraumatic stress disor- healthcare settings. der in the National Co-morbidity Survey. Archives Regan-Kubinski, M. J. (1995). Clinical judgment in of General Psychiatry, 52, 1048–1060. psychiatric nursing. Perspectives in Psychiatric Epidemiological data on all aspects of PTSD: causes, Care, 31(3), 20–24. prevalence, co-morbidity, duration, and sociodemo- This article stresses the importance of the nurse’s use of graphic correlates. his or her experience and judgment in the contemporary Kinzie, J. D., & Manson, S. M. (1987). The use of self- healthcare environment. rating scales in cross-cultural psychiatry. Hospital Sadock, B. J., Kaplan H. I., & Sadock V. A. (2003). & Community Psychiatry, 38(2), 190–196. Kaplan & Sadock’s synopsis of psychiatry: Behavioral The authors review the use of seven psychiatric self-rating sciences, clinical psychiatry (9th ed.). Baltimore: scales and discuss their usefulness across cultures. Williams & Wilkins. Koenig, H. G., George, L. K., & Titus, P. (2004). Reli- This text targets psychiatrists in training; thus, the au- gion, spirituality, and health in medically ill hos- thors tend to stress the biologic aspect of assessment pitalized older patients. Journal of American Geri- (i.e., genetics, brain anatomy and physiology, neu- atrics Society, 52(4), 554–562 rotransmitters). It is an excellent reference for psychi- This nursing research study, based on patient interviews atric nurses. conducted at Duke University, identifi ed measures of re- Schreiber, R. (1991). Psychiatric nursing assessment: A ligiosity and spirituality. Religiousness and spirituality la King. Nursing Management, 22(5), 90–94.

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This article outlines an effi cient psychiatric nursing as- concerning transference, countertransference, and resis- sessment model based on King’s nursing theory. tance generalizes to group and individual treatment of all Terkelson, K. G. (1987). The meaning of mental illness psychiatric clients. to families. In A. Hatsfi eld & H. Lefl ey (eds.), Vedantam, S. (2005, June 26). Patients’ diversity is of- Families of the mentally ill (pp. 128–166). New ten discounted. The Washington Post, pp. A01, York: Guilford Press. A10. This chapter provides a conceptual framework for viewing This article contains a discussion of how the presentation the family’s experience of a relative’s mental illness. The of mental illness differs across cultures. chapter discusses several factors associated with the family Woods, M. E., & Hollis, F. (2000). Casework: A psycho- and the mentally ill relative that impact upon the meaning social therapy (5th ed.). New York: McGraw-Hill. of the illness to the family. Although this book is intended for caseworkers and not Terr, L. C. (1991). Childhood traumas: An outline and nurses, it contains useful information regarding the overview. American Journal of Psychiatry, 148(1), therapeutic relationship that applies to a wide range of 10–20. mental health professionals. This article investigates those aspects of childhood trau- ma that follow the patient into adulthood. The author delineates the consequences of single versus multiple Internet Resources childhood traumas and provides helpful case examples. Vannicelli, M. (1992). Removing the roadblocks: Group psychotherapy with substance abusers and family members. New York: Guilford Press. Although this book’s focus is the specialty area of group therapy for substance abusers, the excellent information

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