Assessing the Mentally Ill Patient: Part 2

In last week’s post we were preparing to assess an inmate at the county jail, who the custody staff described as “going nuts”. With an accurate assessment our goal is to seek the most appropriate and immediate help for the patient. We reviewed his record and decided that the best place to interview him at this time is the cell front.

A nursing assessment of mental health is similar to the assessment of a physical status.  It consists of asking questions of the patient about their symptom and treatment experience (subjective assessment) while at the same time observing the patient’s behavior, activity and expressions (objective assessment).  The table below lists the clinical signs and symptoms that are evaluated in a mental health assessment.  It can be used as a quick reference to make sure your assessment is comprehensive. For more detail about each of these areas see Chapter 12 of the Essentials of Correctional Nursing.

Component Areas   Assessed Method
Appearance Dress &   Hygiene Observation
Behavior Expression   & Motor Activity Observation
Speech Rate, Tone,   Manner, Content Observation
Cognition Orientation,   Memory, Attention, Insight Interview
Mood Patient’s   description of how they feel Interview
Affect Expression   of emotion Observation
Thoughts Form &   Content Interview
Perception Hallucinations Interview

We arrive on the unit and check in with the correctional officer who called with concerns about the inmate and then go see the patient. After introductions we engage the patient in purposeful conversation; asking about the time of day, his activities, and how he is feeling. We may ask him to carry out a request or recall a recent event. As our interaction takes place we are listening carefully and observing the patient’s behavior noting his cognition, emotions, their expression and thought processes. We follow up on his responses to fill in detail, provide support and offer reassurance.

Nurses make significant contribution to good patient outcomes by skilled observation.  Describing a patient’s health status, especially signs and symptoms that deviate from “normal” is much more useful in determining the plan of care than use of psychiatric terminology and diagnostic labels. In the following documentation of our patient assessment we do not use elaborate or specialized psychiatric terminology.

S:  23 yo male, first incarceration, received 72 hours ago on charge of reckless driving. On intake denies ETOH and/or drug use. No history of MH treatment. At 22:00 h officers requested help w/ inmate “going nuts”.  According to custody he has not rested or eaten over the last 24 hours.

O:    Pt. appears disheveled; not having shaven or washed hair for several weeks, observed pacing the cell. Minimal eye contact, no direct response to questioning, verbalizes random words that are not connected logically to one another.  Does not comply when directed to approach the cell front or sit on bunk. Withdraws to cell corner and random hand movements increase when spoken to. Patient appears to be rolling fingers and picking at air, this activity increases in pace and emphasis during the assessment. No self-harm behavior was observed.”

Basic survival advice for correctional nurses conducting a mental health assessment is to remember that:

1. Both mental and physical health assessments are formed by the collection of subjective and objective information.

2. The mental health assessment considers the patient’s appearance, cognition, emotion and thought processes.

3. Comprehensive, descriptive information is more valuable in determining the plan of care than use of specific psychiatric terminology or labels.

Based upon the description of the patient what is your assessment and nursing diagnosis?  What is your plan for the patient? We will pick up here on the next post.

If you haven’t already order your copy of the Essentials of Correctional Nursing directly from the publisher at http://www.springerpub.com/product/9780826109514#.UDqoiNZlQf4

Photo Credit: © Michael Brown

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