Practical Guide to Mental Health Nursing W Vimala Samson
INDEX
×
Chapter Notes

Save Clear

ASSESSMENT FORMATChapter 1

 
MENTAL HEALTH NURSING
 
OVERALL OBJECTIVE
The student is able to provide curative, preventive, promotive and rehabilitative care to patients with psychiatric disorders in the hospitals. It will help students to develop advanced skills for nursing intervention in various psychiatric conditions.
 
SPECIFIC OBJECTIVE
The student is able to:
  1. Describe the current trends and scope in mental health nursing.
  2. Describe the national mental health nursing act, programme and mental health policy.
  3. Demonstrate therapeutic communication skills in all interactions.
  4. Explain the principles and standards of mental health nursing.
  5. Provide comprehensive care to patients with psychiatric disorders.
  6. Explain dynamics of human behaviour in different situations.
  7. Describe the magnitude of psychiatric problems and trends in psychiatric care.
  8. Explain assessment, etiology, psychopathology, clinical manifestations, evaluation and management of various psychiatric disorders of child, adolescence and old age.
  9. Apply different principles and concepts into every aspect of nursing care.
  10. Explain treatment modalities, various therapies, guidance and counseling used in mental disorders and role of the nurse.
  11. Provide holistic care to individual with various psychiatric disorders in the hospital using nursing and other techniques.
  12. Develop desirable attitudes.
2
 
HISTORY TAKING OF PATIENTS WITH MENTAL ILLNESS
  1. SOCIODEMOGRAPHIC DATA
    1. Name:
    2. Father's/Spouse's name:
    3. Address:
    Rural/Urban
    4. Age:
    5. Sex:
    6. Language —
    Mother tongue:
    Other Languages:
    7. Marital status:
    1. Single
    2. Married
    3. Separated
    4. Divorced
    5. Widow
    6. Widower
    7. Other
    8. Education:
    9. Occupation:
    10. Income (per month):
    11. Religion:
    12. Informant: Relationship with the patient:
  2. PRESENTING COMPLAINTS
    Includes onset of present illness, duration of present illness, course, precipitating factors, Aggravating, maintaining, and/or relieving factors, if any:
    1. ____________________________________
    2. ____________________________________
    3. ____________________________________
    4. ____________________________________
    5. ____________________________________
    6. ____________________________________
  3. HISTORY OF PRESENT ILLNESS
    • Duration of total illness: (wks/months/yrs)
    • Current: episode/exacerbation
    • Mode of onset: Abrupt < 48 hr/Acute < 1 wk/Sub acute 1–2 wk/Insidious
    • Course: Continuous/Episodic/Unclear/Fluctuating/Deteriorating/Improving.
    • Precipitating factors: (describe)
    3
    Description:
    (In cases of long duration, divide into initial, middle and recent phases)
    (Chronological account, describe major abnormal behaviour, associated problems like homicide/suicide/disruptive behaviour, thought contents as expressed in speech/writing, major mood states, abnormal perceptions and experiences, biological functioning, interpersonal and social functioning, occupational functioning, changes in daily life, etc.)
    (Scheme for substance abuse/dependence cases)
    Mode of initiation, early pattern of intake, progression, salience, tolerance, craving, physical withdrawal features, pattern of use in recent past, medical complications (including accidents, neuro psychiatric problems, interpersonal problems, socio-economic problems (including debts, if any), occupational problems, problems with law, earlier attempts to abstain, reason for consultation, motivation for abstinence, etc. (In case of multi substance use, describe separately for each substance)
    Treatment History:
    • (Magi co-religious/other systems
    • (Homeopathy/Ayurveda/Allopathic (Medical))
    • Psychiatric (Present)
    Pharmacotherapy:
    List drugs as far as possible from to dose response side effect.
    ECTS:
    • Psychotherapy:
    • Family interventions:
    • Rehabilitative measures:
    Negative History:
    • Major features that are usually present in the given syndrome
    • Other associated major syndromes
    • Other major Psychiatric illness Organic causes
    • Substance uses.
  4. PAST HISTORY (CHRONOLOGICAL ACCOUNT SINCE CHILDHOOD)
    Describe each episode briefly, with onset, major features, course and duration, interventions level of recovery).
    • Psychiatric illness:
    • Medical illness:
    4
  5. FAMILY HISTORY
    1. Family tree (pedigree) (Draw the tree for 3 generations on both sides in cases of genetic importance.
    2. Describe each family member briefly (Relationship, age, education, occupation, age at death, mode of death, health status physical and psychological, major personality traits, relationship with client, include other significant members).
    3. Details of family functioning
      1. Type of Family: (Nuclear/Joint/Other)
      2. Social economic status: (Upper/Middle/Lower)
      3. Leadership
      4. Communication
      5. Child rearing practices
      6. Interpersonal relationships
      7. Social position
      8. Social support systems
      9. Other.
    History of illness in family: Psychiatric: Similar illness, Other illness, Other major behavioral problems like delinquency, personality problems, suicide, substance use, epilepsy, mental retardation.
    Medical: (especially hereditary).
  6. PERSONAL HISTORY
    Birth and development:
    • Antenatal period: Uneventful/Eventful (specify)
    • Birth History: (Full term/premature/post mature/normal/forceps/cesarean/delayed birth cry/any other problems.
    • Postnatal history: Uneventful/eventful (specify)
    • Physical health during infancy: Good/poor (specify)
    • Immunization schedule: completed/not completed
    • Developmental milestones: Normal/delayed
    • Childhood health: Normal/abnormal/trauma/fever/convulsions/any other illness
    • Behavioral and emotional problems: Nail biting, enuresis, sleep walking, temper tantrums, Stammering)
    • Emotional problems in adolescence: Running away/delinquency/Smoking/drug taking/overweight/identity problems.
    • Home atmosphere during adolescence: Satisfactory/unsatisfactory
    • Parental lack: Yes/No (Dead, separated for more than one year, habitually absent from home
      5
    • Anomalous family situation: Yes/No (Step parent adoption status)
      Comments:
  7. EDUCATIONAL HISTORY
    Age of beginning:
    Age of finishing:
    Grade reached:
    (if discontinued, reason for it)
    Relationship with teachers:
    Relationship with school mater (include nickname, bully/butt of jokes):
    Position in class: (Top, Middle, Low)
    Special abilities:
    Active participation in games: Yes/No
    Other extra curricular activities:
  8. OCCUPATIONAL HISTORY
    Work record: Satisfactory/unsatisfactory frequent changes of jobs: Yes/No
    Work position: Rising/Failing/Stationary
    Age at the time of starting to work:
    Jobs held in the past (in chronological order, with wages, dates, reasons for change).
    1. ____________________________________
    2. ____________________________________
    3. ____________________________________
    4. ____________________________________
    5. ____________________________________
    Present Job:
    Duration:
    Satisfied with work: Yes/No (Reasons for dissatisfaction)
  9. SEXUAL HISTORY
    Information about sex (How acquired, of what kind, how received, adequacy of knowledge, attitude towards, opposite sex)
    • Masturbation: Age of starting: Frequency (Guilt if, any)
    • Sexual experiences: (Home/Hetero/Pre and extramarital/Preference)
    • Any complaints including Dhat:
    6
  10. MENSTRUAL HISTORY
    Age at menarche/how regarded/regularity/duration/cycle/amount/physical/emotional problems
    • LMP:
    • Menopause: (Age/climacteric symptoms)
  11. MARITAL HISTORY (GENOGRAM/FAMILY OF PROCREATION)
    • Date/Year of marriage: Arranged/Affair
    • Spouse: Age, Education, Occupation, Personality
    • Marital relationship: Satisfactory/Unsatisfactory
    • Contraceptive practices:
    • Children: Chronological list of children/miscarriage and still births (age, education, occupation, personality for each child, relationship with client).
  12. PREMORBID PERSONALITY
    Give details and cite examples from patients past life.
    1. Social relations
    2. Intellectual activities: Hobbies and interests:
    3. Mood (Cheerful, strung on, optimistic, pessimistic, stable, fluctuating, etc.)
    4. Character
      1. Attitude to work and responsibility
      2. Interpersonal relationships
      3. Standards in moral, religious, Social and health matters.
      4. Energy and initiative
    5. Fantasy life: (Day dreaming - content and frequency)
      Habits:
      Eating foods/patterns:
      Sleeping patterns:
      Excretory functions:
      Alcohol consumption:
      Tobacco consumption:
      Self-medication with drugs:
 
MENTAL STATUS EXAMINATION OF PATIENTS WITH MENTAL ILLNESS
  1. General Appearance and Behavior
    • Appearance: Looking one's age/order/younger
    • Level of growing: Normal/shabbily dressed/over dressed
    • Level of cleanliness: A adequate/inadequate/overtly clean
      7
    • Level of consciousness: Fully conscious and alert/drowsy/stuporous/comatose
    • Mode of entry: Came willingly/Persuaded/Brought physically
    • Cooperativeness: Normal/More than so/Less than so
    • Eye-to-Eye contact: Maintained/Difficult/Not maintained
    • Psychomotor activity: Normal/Increased/Decreased
    • Empathy: Easy/Difficult/Sustained/Unclear
    • Rapport: Spontaneous/Difficult/Not established
    • Quality of rapport: Good/Poor
    • Gesturing: Normal/Exaggerated/Bizarre
    • Posturing: Normal posture/Catatonic posture
    • Other movements: Mannerisms/Stereotypic/Tremors/EPS/AIMS/Preservation
    • Other catatonic phenomena: Automatic obedience/Negativism/Cooperation/Waxy flexibility/Echoproxia.
    • Details:
  2. Speech
    • Initiation: Spontaneous/speaks when spoken to/minimal/mute
    • Reaction time: Normal/Delayed/Shortened/Difficult to assess.
    • Speed: Normal/Slow/Rapid/Not clear
    • Output: Normal/Increased/Decreased/Variable
    • Pressure of speech: Present/Absent
    • Volume: Normal/Increased/Decreased
    • Tone: Normal variation/Monotonous
    • Manner: Normal/Highly formal/In appropriately familiar
    • Relevance: Fully relevant/Sometimes off target/Irrelevant
    • Coherence: Fully coherent/Over elaborate, digressive, circumstantial speech/Some
    • Loosening of associations/Incoherent
    • Others: Rhyming/Punning/Echolalia/Preservation/Neologism
    • Sample of speech (in response to open ended questions)
  3. Thought
    • Tempo: Normal/Racy thoughts/Flight of ideas/Retarded thinking/Muddled/Unclear thinking/Thought block/Circumstantiality's/Tangentially.
    • Form: Adequate/Wooly and vague thinking/Loosening of associations/Gross
    • Formal thought disorder (FTD) (Refer to sample of speech for examples of disorders of tempo and form)
    8
  4. Obsessive-compulsive Phenomena
    • (Major content/Interference/Distress/Recognition of in appropriateness/Resistance)
    • Obsession: (Thought/Doubt/Impulse/Image/Rumination)
    • Compulsion: (Yielding/Controlling/Mental compulsion)
    • Examples: Thought alienation phenomena (Thought insertion/withdrawal/Thought broadcast).
    • Thought contents: (Idea/over valued idea/delusion)
    • (Worthlessness/Helplessness/Hopelessness/Guilt/Ill health)
    • Poverty/Nihilistic/Hypochondriac/Death wish/Suicidal Grandiose Ability and Identity/Reference/Ideas/Control/Influence/Persecution/Bodily change/Religious/Bizarre)
    • (Single/Multiple/Simple/Elaborate/Systematized/Nonsystematized/Mood congruent/Incongruent/Degree of distress/Interference with work/Reaction to phenomena)
    • Examples:
  5. Mood
    • Subjective:
    • Objective:
    • (Predominant mood state/Other major moods/Range/Reactivity/Quality (Mood/Communicability/Liability/Appropriateness/Congruence/Emotional expression):
    • Normal/Blunted flattened/Made affect)
    • Description:
  6. Perception
    Hallucination: Pseudohallucination
    Single/multiple
    Auditory: Illusion
    One modify/Many modalities
    Visual depersonalizations
    Elementary/Partially formed/Fully formed
    Olfactory:
    Gustatory
    Derealization
    Occasional/Continues
    Deja Vu phenomena
    Mood congruent/Mood incongruent
    Tactile
    Degree of distress
    Somatic
    Reaction to phenomena special
    9
  7. Cognitive function
    Attention: Normally aroused/Aroused with difficulty
    Digit forward:
    Digit backward:
    Concentration:
    Normally sustained/Sustained with difficulty/Distractible
    100
    –
    7
    40
    –
    3
    20
    –
    1
    Name of months (backwards)
    Name of week days (backwards)
  8. Orientation
    Time
    : Approximate time/Day-night/Date/Day/Month/Year/……..
    Place
    : Kind of place/Area/City………..
    Person
    : Self/Close associate/Hospital staff
  9. Memory
    Immediate (Same test as for attention)
    Recent: Recent happenings (last meal/visitors, etc.)
    Verbal recall
    after 5 min
    after 10 min
    3 unrelated objects/
    …………..
    …………..
    5 unrelated objects/
    …………..
    …………..
    Imaginary address if 5 times
    …………..
    …………..
    Visual recall 3 or 5 unrelated Objects
    …………..
    …………..
    Remote:
    Personal events
    …………..
    …………..
    Impersonal events
    …………..
    …………..
    Illness related events
    …………..
    …………..
  10. Intelligence
    • Comprehension: Simple commands/Complex commands
    • Vocabulary: Common objects/Uncommon objects/Parts of objects
    • General fund of information: …………..…………..…………..
    • Arithmetic ability: Mental arithmetic, Written sums …………..
      10
    • Details:
    • Abstraction: Normal/Concrete/Personalized/Bizarre
    • Interpretation of proverbs
    • Similarities between paired objects:
    • Dissimilarities between paired objects:
  11. Judgment
    • Intact/Impaired.
    • Personal: (Sense of personal capability/worth and planning of future)
    • Social test: (Sense of what is socially and culturally acceptable)
    • (Prediction of one's own behavior in imaginary situations)
  12. Insight
    Awareness of abnormal behavior/experience
    Yes/May be/No
    Attribution to physical causes
    Yes/May be/No
    Recognition of personal responsibility
    Yes/May be/No
    Willingness to take treatment
    Yes/May be/No
    Grade (1 = No insight, 6 = Full insight)
    Any other information: (Motivation/Willingness for treatment:
    Diagnosis:
 
GENERAL AND PHYSICAL EXAMINATION
Name, Age and Sex
Ward Unit:
Income:
Date:
Time:
 
GENERAL EXAMINATION
 
BODY TYPE: Asthenic/Athletic
Dysthymic, Pyknic:
Temperature:
Anemia:
Pale, Conjunctiva Tongue Pallor of Nail Beds
Nourishment: Good, Moderate, Poor, Emaciated, Dehydrated.
Jaundice:
Sclera, Palate, Skin
Hair: Distribution Normal, Scanty, Hirsutism Alopecia Healthy, Unhealthy.
11
Cyanosis:
Clubbing:
Skin: Dry, scaly, glistening patches, others
Lymph nodes:
Breast:
Other details:
Edema:
Thyroid:
General nervous system:
Level of consciousness:
Handedness:
Speech:
Posture:
Cranial nerves:
Fundi
Pupils
Motor system:
L
R
L
R
Power:
Others
Tone:
Nourishment
Co-ordination:
Cerebellar system:
Involuntary movements:
Gait:
Sensory system:
Reflexes
Superficial:
Deep tendon:
Infantile:
Skull
Spine
Cardiovascular System:
Pulse
Carotids
Radial
Dorsalis
Pedis
JVP
BP
Cardia:
Respiratory System
Abdomen
Contour
Mass:
Tenderness
Organs
Rigidity
Fluid:
Genitourinary and Rectal Examination:
Bones and Joints:
Other Observation:
12
Behavioral Observation:
Mute:
Restless
Stuporose
Aggressive
Psychomotor Retardation
Overtalkative
Suicidal Risk
Escaping Tendencies:
Identification Marks
1.
2.
Date: Signature of the Examination Doctor
Name:
 
NEUROLOGICAL ASSESSMENT
 
DEFINITION
Neurological examination is a method of obtaining specific data in relation to the function of a patient's nervous system.
 
INDICATION
Neurological observations are required to monitor and evaluate changes in the nervous system by indicating trends, thus aiding diagnosis and treatment which in turn may affect prognosis and rehabilitation.
 
HISTORY
Questioning relatives, friends or the ambulance team is an essential part of the assessment of the unconscious or the unco-operative patient.
Has the patient sustained a head injury leading to admission, or in the preceding weeks?
  • Did the patient collapse suddenly?
  • Did limb twitching occur?
  • Have symptoms occurred in the preceding weeks?
  • Has the patient suffered a previous illness?
  • Does the patient take medication?
 
NEUROLOGICAL OBSERVATIONS AND ASSESSMENT
The following describes a full neurological assessment:
13
Special consideration:
  • A fully conscious patient will respond to questions quickly and is alert to events occurring around him. As his condition deteriorates he may display irritability, lack of concentration and uncooperative behavior.
  • A comatose state is one in which the patient fails to respond to verbal and painful stimuli, fever and pain commonly cause confusion, disorientation and irritability.
  • To prevent the patient from falling, stand by the side of the patient during the test.
  • The patient's cultural and educational background influences his ability to answer test questions.
 
EQUIPMENT
1. Cotton applicator
Assesses patients response to light touch.
2. Needle
Assesses patient's response to pain
3. Test tube containing hot and cold water
Assesses temperature sensation.
4. Reflex hammer
5. Vials containing coffee or vanilla extract, sugar salt.
Assesses olfactory nerve
6. Tongue blade
7. Penlight
8. Snellen chart
9. Tuning fork
10. Thermometer
11. BP apparatus
12. Stethoscope
 
NERVOUS SYSTEM—HISTORY
  1. HEADACHE
    • Onset-sudden/gradual.
    • Frequency
    • Severity
    • Character—aching/throbbing
    • Associated features—vomiting/visual disturbance
    • Site
    • Relieving factors—analgesics
    • Precipitating factors—stooping/coughing
    • Timing, e.g. morning
    14
  2. VISUAL DISORDER
    Onset
    Frequency
    Duration
    Precipitating factors
    Impairment:
    One/both eyes
    Total/partial visual loss
    Whole/partial field loss
    Diplopia:
    gaze direction where maximal
    Hallucinations:
    field involved – formed, e.g. images (real)
    Unformed, e.g. shapes or zig-zags.
  3. LOSS OF CONCIOUSNESS
    • Onset
    • Frequency
    Duration precipitating factors
    • Tongue biting
    • Incontinence
    • Limb twitching
    • Alcohol/drug abuse
    • Head injury
    • Cardiovascular or respiratory symptoms
  4. SPEECH DISORDER
    • Onset
    • Frequency
    • Duration
    • Difficulty in articulation
    • Difficulty in expression
    • Difficulty in understanding
  5. MOTOR DISORDER
    • Onset
    • Frequency
    • Duration
    • Precipitating factors, e.g. walking
    • Relieving factors, e.g. rest
      15
    • Incoordination-balance
    • Weakness-progression/clumsiness/difficulty in walking/leg stiffness
    • Involuntary movement.
  6. SENSORY DISORDER
    • Onset
    • Frequency
    • Duration
    • Precipitating factors, e.g. walking, neck movement
    • Relieving factors, e.g. rest
    • Pain
    • Numbness/Tingling
    • Site.
  7. SPHINCTER DISORDER
    • Onset
    • Frequency
    • Duration
    • Bladder and anal
    • Difficulty in control—incontinence/retention.
  8. LOWER CRANIAL NERVE DISORDER
    • Onset
    • Frequency
    • Duration
    • Precipitating factors, e.g. neck movement, head position
    • Deafness/Tinnitus—uni/bilateral.
    • Vertigo—rotation of surrounding
    • Balance/Staggering—direction
    • Swallowing difficulty
    • Voice change.
  9. MENTAL DISORDER
    • Onset
    • Frequency
    • Duration
    • Memory/Intelligence—deterioration
      16
    • Personality/Behavior—change.
    • Nervous system—examination
Neurological disease may produce systemic signs and systemic disease may affect the nervous system. A complete general examination must, therefore, accompany that of the central nervous system. In particular, note the following:
  • Temperature
  • Blood pressure
  • Neck stiffness
  • Pluse irregularity
  • Carotid bruit
  • Cardiac murmurs
  • Cyanosis/respiratory insufficiency
  • Evidence of weight loss
  • Breast lumps
  • Lymphadenopathy
  • Hepatic and splenic enlargement
  • Prostatic irregularity
  • Septic source, e.g. teeth, ears, skin marks, e.g. rashes, café-au-lait spots, angiomata anterior fontanelle/head circumference in baby.
Central nervous system examination is described systematically from the head downwards and includes the following:
Cranial nerves 1–12 nerves.
Conscious level and higher cerebral function
Cognitive skills Memory Reasoning Emotional states.
Upper and lower limbs. Motor system-wasting/ tone/power
Sensory system-pain/touch/temperature/proprioception/Stereognosis Reflexes Co-ordination.
Trunk. sensation Reflexes
sphincters
17
 
CRANIAL NERVE FUNTION AND ASSESSMENT
Note: to be completed on the 12 cranial nerves
Nerve's Name
System
Function
Method of Assessment
1 Olfactory
Sensory
Sense of smell
Ask patient to identify different nonirritating aromas such as coffee powder.
2 Optic
Sensory
Vision
Use Snellen chart: Ask the patient to read printed material.
3 Oculomotor
Motor
Extraocular Eye movement Pupil constriction and dilation.
• Assess direction of gaze
• Measure pupil reaction to 7light reflex
4 Trochlear
Motor
Upward and downward movement of the eyeball
Assess direction of gaze
5 Trigeminal
Sensory and motor
Sensory nerve to skin of face
Motor nerve to muscles of jaw. Assess corneal reflex measure sensation of light, pain and touch across skin of face. Assess patient's ability to clench teeth.
6 Abducens
Motor
Lateral movements of eyeballs
Assess direction of gaze
7 Facial
Sensory and motor
Facial expression
Ask patient to smile, frown, puff out cheeks, raise and lower eye brows
8 Auditory
Sensory
Hearing
Assess patient's ability to hear spoken word.
9 Glosso-pharyngeal
Sensory and motor
Taste ability to swallow
Movement of tongue. Ask patient to identify sour, salty or sweet taste on back of tongue. Use tongue blade to
18
Nerve's Name
System
Function
Method of Assessment
elicit gag reflex. Ask patient to move the tongue.
10 Vagus
Sensory and motor
Sensation of pharynx.
Ability to swallow. Movement of vocal cords. Ask patient to say “ah” observe movement of palate and pharynx. Use tongue bade to elicit gag reflex. Ask patient's speech for hoarseness.
11 Spinal accessory
Motor
Movement of head and shoulders.
Ask patient to shrug shoulders and turn head against examiner's passive resistance.
12 Hypo-glossal
Motor
Position of midline.
Ask patient to stick to tongue.
 
Conscious Level Assessment
Action
Response
Score
Eyes Open
Spontaneously
4
To speech
3
To pain
2
None
1
Best Verbal Response
Oriented
5
Confused
4
Inappropriate words
3
Incomprehensive sounds
2
Best Motor Response
obeys commands
6
localized pain
5
flexion withdrawal
4
abnormal flexion
3
abnormal extension
2
flaccid
1
Total
15
19
  1. COGNITIVE SKILL
    1. Dominant Hemisphere Disorders
      Listen to language pattern – Hesitant
      – Fluent
      Expressive dysphasia
      Receptive dysphasia.
      Does the patient understand simple/complex
      Spoken commands?
      e.g ‘hold up both arms, touch the right ear with the left fifth finger.’
      Receptive dysphasia.
      Ask the patient to name the objects.
      Normal dysphasia.
      Does the patient read correctly?
      Dyslexia
      Does the patient write correctly?
      Dysgraphia
      Ask the patient to perform a numerical calculation, e.g. serial 7 test, where 7 is subtracted serially from 100
      Dyscalculia
      Can the patient recognize objects? e.g. ask the patient to select an object from a group.
      Agnosia
    2. Non-dominant Hemisphere Disorders
      Note patient's ability to find his way around the ward or his home.
      Geographical agnosia
      Can the patient dress himself? Dressing apraxia
      Note the patient's ability to copy a geometric pattern, e.g. ask the patient to form a star with matches or copy a drawing of the cube.
      Constructional apraxia
  2. MEMORY SKILL
    Testing requires alertness and is not possible in a confused or dysphasic patient. • Immediate memory : Digit span—ask patient to repeat a sequence of 5, 6 or 7 random Numbers.
    • Immediate memory
    : Digit span—ask patient to repeat a sequence of 5, 6 or 7 random Numbers.
    • Recent memory
    : Ask patient to describe present illness, duration of hospital stay. Or recent events in the news.
    • Remote memory
    : Ask about events and circumstances occurring more than 5 years. Previously.
    20
    • Verbal memory
    : Ask patient to remember a sentence or a short story and test after 15 minutes.
    • Visual memory
    : Ask patient to remember objects on a tray and test after 15 mints.
  3. REASONING AND PROBLEM SOLVING SKILL
    Test the patient with two-step calculations, e.g. ‘I wish to buy 12 articles at 7 pence each. How much change will I receive from shop?
    Ask patient to reverse 3 or 4 random numbers.
    Ask patient to explain proverbs.
    The examiner must compare patient's present reasoning ability with expected abilities based on job history and/or school work.
  4. EMOTIONAL STATE
    Note:
    • Anxiety or excitement
    • Depression or apathy
    • Emotional behavior
    • Uninhibited behavior
    • Slowness of movement or responses.
 
UPPER AND LOWER LIMBSASSESSMENT OF SENSORY NERVE FUNCTION
Sensory Function
Equipment
Method
Pain
Safety pin
Ask patient to tell you when dull or sharp sensation is felt. Alternately apply pointed and blunt ends of pin to skin's surface. Note areas of numbness or increased sensitivity.
Temperature
Two tests:
• Tube filled with hot water, and
• Tube filled with cold water
Touch patient's skin with tube. Ask client to identify hot/cold sensation.
Light Touch
Cotton ball or cotton tip applicator.
Apply light wisp of cotton to different points along skin surface. Ask patient to tell you when sensation is felt.
21
Vibration
Tuning fork
Apply vibrating fork to distal inter-phalageal joint of great toe.
Position
Grasp patient's finger, holding it by its sides with your thumb and index finger. Alternate moving finger up and down. Ask patient to tell you whether finger is up or down. Repeat procedure with toes.
Two-point Discrimination
Two safety pins
Lightly apply points of two safety pins simultaneously to skin's surface. Ask if patient feels one or two pinpricks.
 
MOTOR SYSTEM—UPPER LIMBS
Appearance—Asymmetry or deformity
  • Muscle wasting
  • Muscle hypertrophy
  • Muscle fasciculation.
Tone—Try to relax the patient and alternately flex and extend the knee joint.
  • Note the resistance.
Power—When testing each muscle group, think of root and nerve supply.
Test
Nerve
Method
Test for Serratus Anterior
C5, C6, C7 roots long thoracic nerve
Patient presses arms against wall Look for winging of scapula
Shoulder Abduction
Deltoid: C5, C6 roots axillary nerve.
Arm (at more than 15″ from the vertical). Abducts against resistance.
Elbow Flexion
Biceps: C5, C6, roots musculocutaneous nerve. Brachioradialis: C5, C6 roots Radial nerve
Arm flexed against resistance with the hand fully supinated. Arm flexed against resistance with hand in mid-position between pronation and supination
Elbow Extension Finger Extension
Triceps: C6, C7, C8 roots Radial nerve Extensor digitorum: C7, C8 roots posterior inter-osseous nerve.
Patients extends arm against resistance.
Patients extends fingers against resistance.
22
Thumb Extension-Terminal Phalanx
Extensor pollicis longus and brevis: C7, C8 roots posterior inter-osseous nerve.
Thumb is extended against resistance.
Finger Flexion-Terminal Phalanx
Flexor digitorum profundus I and II: C7, C8 roots median nerve. Flexor digitorum profundus III and IV: C7, C8 roots ulnar nerve.
Examiner tries to extend patient's flexed terminal phalanges.
Thumb Opposition
Opponens pollicis: C8, T1 roots, median nerve.
Patient tries to touch the base of the 5 th finger with thumb against resistance.
Finger Abduction
1st dorsal interosseus: C8, T1 roots, ulnar nerve. Abductor digiti minimi: C8, T1 roots. Ulnar nerve.
Fingers abducted against resistance.
 
MOTOR SYSTEM—LOWER LIMBS
Appearance—Asymmetry or deformity.
  • Muscle wasting
  • Muscle hypertrophy
  • Muscle fasciculation.
Tone—Try to relax the patient and alternately flex and extend the knee joint.
Note the resistance.
Power—When testing each muscle group, think of root and nerve supply.
Test
Nerve
Method
Hip Flexion
llio-psoas: L1, L2, L3 roots. Femoral nerve.
Hip flexed against resistance.
Hip Extension
Gluteus maximus: L5, S1, S2 roots. inferior gluteal nerve.
Patient attempts to keep heel on bed against resistance.
Hip Abduction
Gluteus medius and minimus and tensor fasciae latae: L4, L5, S1 roots. Superior gluteal nerve
Patient lying on back tries to abduct the leg against resistance.
23
Hip Adduction
Adductors:L2, L3, L4 roots. Obturator nerve.
Patient lying on back tries to pull knees together against resistance.
Knee Flexion
Hamstrings: L5, S1, S2 roots. Sciatic nerve
Patient pulls heel towards the buttock and tries to maintain this position against resistance.
Knee Extension
Quadriceps: L2, L3, L4 roots. Femoral nerve
Patient tries to extend knee against resistance.
Dorsi Flexion
Tibialis anterior: L4, L5 roots. Deep peroneal nerve.
Patient dorsiflexes the ankle against resistance. May have difficulty in walking on heels.
Plantar Flexion
Gastrocnemius, soleus: S1, S2 roots. Tibial nerve.
Patient plantarflexes the ankle against resistance. May have difficulty in walking on toes before weakness can be directly detected.
Toe Extension
Extensor hallucis longus, extensor digitorum longus:L5, S1 roots. Deep potoneal nerve.
Patient dorsiflexes the toes against resistance.
Inversion
Tibialis postorior L4, L5 root. Tibial nerve.
Patient inverts foot against resistance.
Eversion
Peroneous longus and bravis: L5, S1 roots. Superficial peroneal nerve.
Patient everts foot against resistancess
 
ASSESSMENT OF REFLEXES:
 
Deep Tendon Reflexes
Type
Procedure
Normal Reflex
Biceps
Flex patient's arm at the elbow with palms down. Place your thumb in the cubital fossa at base of the biceps tendon. Strike thumb with the reflex hammer.
Flexion of arm at elbow.
24
Triceps
Flex patient's elbow holding arm across the chest or hold upper arm horizontally and allow lower arm to go limp. Strike the triceps tendon just above the elbow.
Extension at elbow.
Patellar
Have patient sit with legs hanging freely over side of the bed or chair or have patient lie supine and support the knee in a flexed position. Briskly tap the patellar tendon just below the patella.
Extension of lower leg at knee.
Plantar
Have patient lie supine with legs straight and feet relaxed. Take handle end of the reflex hammer and stroke the lateral aspect of the sole from the heel to the ball of the foot curving across the ball.
Flexion of toes.
 
Trunk
Sensation Reflexes
Test pin prick and touch in dermatome distribution as for the upper limb.
Levels to remember:
T5-at nipple
T10-at umbilicus
T12-at inguinal ligament.
Abdominal reflexes: T7-T12 roots. Stroke or lightly scratch the skin towards the umbilicus in each quadrant in turn. look for abdominal muscle contraction.
 
Sphincters
Examine abdomen for distended bladder.
Note evidence of urinary or faecal incontinence.
Anal reflex: S4, S5 roots.
A scratch on the skin bedside, the anus causes a reflex contraction of the anal sphincter.
25
 
PROCESS RECORDING
 
 
Definition
Process recording is a written account or verbatim recording of all that transpired immediately before, during and immediately following the nurse-patient interaction.
 
Purpose
  • Assist to plan, structure and evaluate the interaction.
  • Gain competency in interpreting and syntherizing raw data.
  • Apply theory into practice.
  • Increased awareness of her habitual, verbal and nonverbal communication patterns.
  • Identify thoughts and feelings.
  • Increase observation skills.
  • Ability to identify problems and gain skills in solving them.
 
Uses
  • Educative tool.
  • Teaching tool.
  • Diagnostic tool.
  • Therapeutic tool.
  • Pre-requisite for nursing process.
 
Pre-requisite for process recording
  • Physical setting.
  • Getting consent of the patient for the possibility of cassette recording.
  • Confidentiality.
 
Procedure
  • Introductory material.
    • ¤ Short description of the patient [name, age, sex, ect.]
    • ¤ Date, time, and place.
    • ¤ Thoughts and feelings.
    • ¤ Duration.
  • Objectives—Short term goal and long-term goal.
  • Record of interaction between nurse and the patient.
    • ¤ Verbal response.
    • ¤ Non verbal response.
    • ¤ Self evaluation.
    26
  • Analysis of the interaction.
    • ¤ Interpretation of the verbal and non verbal responses.
    • ¤ Thoughts and feelings.
    • ¤ Communication techniques.
    • ¤ Total time 30 mints. [Active time 20 mints and 10 mints for conclusion.]
 
VERBATUM
Name:
Age:
Sex:
Place:
Date and time:
Situation:
Day of admission:
Objectives of the interview:
1)
2)
3)
Nurse Verbal Response
Nurse Non Verbal Response
Patient Verbal Response
Patient Non Verbal Response
Inference
Conclusion:
Summary: