1. Donna C. Semar PhD., RN, CHSE

2. Appearance Start with an assessment of the patient’s general appearance. Important things to notice include: Is the patient clean, well groomed, neatly dressed? Is he/she appropriately dressed for the weather or situation? Are the clothes clean, well-fitted, fastened properly? How is the patient’s general hygiene (including mouth care)? Poor personal hygiene can indicate depression, dementia, eating disorders.

3. Appearance Assess the patient’s overall posture. Are they erect منتصب - مشدود, slumped over يتراجع, curled up منطوي مثل الكرة in the fetal position, etc.? What is the patient’s facial expression? Does it match the verbal communication or is it inappropriate? Does the patient appear his/her stated age, older, younger?

4. Behavior Pay attention to what the patient is doing and how he/she is doing it. Are they: Isolated, withdrawn, engaged in activities? Isolated or withdrawn behavior can indicate depression or suspiciousness شكاك that may be related to delusional اعتقادات خاطئة thoughts. Assess eating and sleep patterns to determine whether changes have occurred? Is the patient loud, intrusive اقتحامي تدخلي تطفلي, energetic نشيط ?

5. Behavior Is the patient exhibiting self-destructive مدمر ذاتى, self- injurious or ritualistic behavior طقوس ? Is the patient aggressive? What is the character of the patient’s speech? Is it normal in rate and productivity انتاجى, slow, or rapid?

6. Cognition: Thought Content محتوى الفكر أو الإدراك أو المعرفة Thought content: refers to what material appears in a patient’s consciousness. Check for suicidal or homicidal ideation or intent. Assess whether recent and remote memory يتذكر البعيد are intact سليمة. Determine whether the patient’s general fund of knowledge is appropriate for his/her age and education level.

7. Cognition: Thought Content Delusion: false belief that is firmly maintained, not shared by others or supported by reality. Delusions may be religious, somatic, grandiose or paranoid. Hallucination: perceptual experience that occurs in any of the five senses without any observable stimulus. Illusion: misinterpretation of perceptual stimulus. Obsession: idea, emotion or impulse that repetitively and insistently forces إصرار أو إلحاح itself into consciousness though it is not wanted. على الرغم من أنه ليس مطلوبا

8. Cognition: Thought Content Thought broadcasting: belief that one’s thoughts are being aired to the outside world. أفكار قادمة إليه من الخارج Thought insertion: belief that thoughts are being placed into one’s mind by outside people or influences. Depersonalization: feeling of having lost one’s identity. Derealization: one’s experience of the external world seems strange or unreal. Ideas of reference: incorrect interpretation of external events as having direct personal references.

9. Cognition: Thought Process Thought process: refers to the way in which a person thinks, the patterns and forms of verbalization. Assess whether thoughts are clear, coherent مترابط, goal- directed, tangential, etc. Can you follow what the train of thought is or are you getting confused or lost? Is the person confused, disoriented (person, place, time)? Is the patient capable of abstract thought? Does the patient have any insight بصيرة into his/her current difficulties?

10. Cognition: Thought Process Circumstantial: excessive and unnecessary detail that is relevant to the question and eventually leads to an answer. Flight of ideas: rapid shifting from one topic to another; though one can follow the connections, ideas become fragmented. Loose associations: lack of logical relationship between thoughts and ideas that renders speech vague, inexact, and unfocused.

11. Cognition: Thought Process Neologisms: new words created by the patient Perseveration: excessive continuation or repetition of a single response, idea or activity. Tangential: similar to circumstantial but never answers the question or returns to the central point. Thought blocking: sudden stopping in the train of thought or in the middle of a sentence. Word salad: series of words that seem totally unrelated.

12. Descriptive terms: Mood Mood: the patient’s self-report of his/her prevailing internal emotional state. Sad/depressed Despairing يائس Irritable Elated/euphoric Anxious Guilty Labile

13. Descriptive terms: Affect Affect: the patient’s apparent emotional tone as observed externally. Congruent (matching) the patient’s mood. Constricted or limited: diminished in range or intensity Flat: absence of emotional expression Appropriate vs. inappropriate: matches the situation at hand.

14. Descriptive terms: Behavior Behavior: any observable, measurable act, movement or response. Motor activity: tremors, gestures, hyperactivity, restlessness, agitation, aggressiveness, rigidity, psychomotor retardation, tics or stereotypical movements. Speech patterns: slow, rapid, pressured, volume, aphasia General attitude: cooperative, friendly, hostile, defensive, attentive, guarded, suspicious. Impulse control: ability to control impulses related to aggression, hostility, fear, guilt, affection, sexual feelings.

15. Diagnosis: Medical DSM Multi-axial evaluation system: Axis I: Clinical disorders and other conditions that may be a focus of clinical attention (excludes personality disorders and MR) Axis II: Personality disorders and MR Axis III: Medical conditions Axis IV: Psychosocial and environmental problems (homelessness, unemployment, support, housing) Axis V: GAF (scale of 1-100, higher number=better functioning)

16. Nursing Process: Diagnosis Identified problems with assignment of priority. Complements, not competes with, medical diagnosis. Problem: Alteration in health status requiring nursing intervention Related to: cause or etiology As evidenced by: behaviors, signs, symptoms

17. Priorities: Maslow Physiologic: food, water, shelter Safety/security: domestic abuse Love and belonging: lack of social support Self-esteem: normal activities Self-actualization: personal goal attainment

18. Nursing Process: Outcome Identification and Planning A shared process with the patient. What are the relevant goals. Respect each patient’s culture, strengths, limitations, resources, preferences, and time limits. Make sure goals are specific and measurable. Planning should be individualized. It is a dynamic rather than a static process.

19. Nursing Process: Implementation, Evaluation and Documentation Implementation: Who will do what? Independent: without written orders and within the scope of practice of the nurse Dependent: oral or written orders Collaborative: nurse and team work to improve the patient’s health status. Evaluation: Are we there yet? Documentation: accurate, specific, timely. http://view.officeapps.live.com/op/view.aspx?src=http%3A%2F%2Fw ww.ucare.org%2Fproviders%2FDocuments%2FBriefMentalStatusEx am%2520.docx

20. References Stuart, G. & Laraia, M. (2001). Principles and practice of psychiatric nursing (7 th ed.). St. Louis: Mosby. Townsend, M. (2001). Psychiatric mental health nursing: Concepts of care in evidence-based practice. Philadelphia: F. A. Davis.