Psychiatric Nursing Assessment and Clinical Management
Posted by Anonymous and classified in Psychology and Sociology
Written on in 
English with a size of 3.5 KB
Mental Status Assessment
- Level of consciousness
- Orientation: Person, place, and situation
- Speech, Mood, and Affect
- Thought process and content
- Perception: Hallucinations
- Insight and judgment
Glasgow Coma Scale (GCS)
- Eye opening (4)
- Verbal response (5)
- Motor response (6)
- Total: 3–15 (≤8 indicates severe neurological impairment)
Screening Tools
- CAGE: Drinking problem screen
- CIWA-Ar: Alcohol withdrawal (>15 indicates moderate/severe withdrawal)
- COWS: Opioid withdrawal assessment
Schizophrenia: Clinical Features
A disorder characterized by altered thought, perception, emotion, and behavior.
- Positive Symptoms: Delusions, hallucinations, disorganized thinking, abnormal motor behavior.
- Negative Symptoms: Flat affect, avolition, alogia.
- Thought & Speech Patterns: Word salad, clang associations, neologisms, echolalia, tangentiality vs. circumstantiality, and concrete thinking.
Phases of Schizophrenia
- Acute: Active psychosis.
- Stabilization: Symptoms decrease.
- Maintenance: Baseline function and life skills.
Priority Nursing Diagnoses
- Risk for violence (self/others)
- Disturbed thought processes
- Sensory-perceptual disturbances
- Impaired verbal communication
- Self-care deficit
Nursing Interventions
- Maintain safety.
- Use clear, simple language.
- Do not reinforce delusions.
- Present reality calmly.
- Encourage medication adherence.
- Reduce environmental stimuli.
Personality Disorders
Features include impaired self-identity, relationship problems, poor insight, and long-term, complex treatment needs.
PD Types
- Paranoid: Suspicious
- Narcissistic: Grandiose
- Borderline: Mood swings, self-harm
- Dependent: Cannot decide
- Obsessive-Compulsive: Control
- Histrionic: Attention-seeking
- Antisocial: Disregard for others
- Avoidant: Fear of rejection
Nursing Priorities
- Safety first.
- Consistent boundaries.
- Team communication (to prevent splitting).
- Assess self-harm risk.
Concurrent Disorders
The presence of both a substance use disorder and a mental health disorder.
- Alcohol-related brain disorders:
- Wernicke’s encephalopathy: Acute, reversible.
- Korsakoff’s syndrome: Chronic, poor recovery.
- IV Drug Use Risks: HIV, Hepatitis, Endocarditis, Cellulitis.
Psychoactive Substance Use
- Definitions: Addiction vs. tolerance vs. withdrawal.
- Approaches: Harm reduction vs. abstinence.
Priority Assessments
- Withdrawal severity
- Overdose risk
- Suicide/homicide risk
- Medical complications
- Readiness for change