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- by NCindasun21 Mar 15, '11Hello fellow psychics
I'm trying to put together a "cheat sheet" of sorts on documentation for a new grad nurse I'm working with. While looking at some charts I noticed that many nurses start their notations with "Pt exhibits labile affect and irritable mood". Can you get any more bland?
I can explain to her that affect is something you can see, the expression of feelings or emotions. But how do I explain mood? This definition I found doesn't speak to how the observer can determine the mood.
"Mood - A pervasive and sustained emotion that colors the perception of the world. Common examples of mood include depression, elation, anger, and anxiety. In contrast to affect, which refers to more fluctuating changes in emotional "weather," mood refers to a more pervasive and sustained emotional "climate." Types of mood include: dysphoric, elevated, euthymic, expansive, irritable."
In working with kids, they don't always have words to explain their moods so they usually respond "Fine". I've been doing this a while and I can "feel" their mood but I don't know how to explain it to someone new to it. Any help would be greatly appreciated.
- Mar 15, '11 by elkparkI am an "old school" purist (just warning you up front ), and was taught and continue to believe and teach that the difference between "affect" and "mood" is that affect is the external component that you, as another individual, can observe and draw your own conclusions about, but mood is the internal component of how the individual is feeling "on the inside." You can only assess mood by asking the individual how s/he is feeling -- and whatever s/he tells you is the answer that should be documented, even if it doesn't correspond to what you're observing (however, you are certainly free to document in what ways the client's affect and behavior are incongruous with the stated mood -- and you are free to probe further, and ask more in-depth questions, than simply asking, "How are you feeling?").
- Mar 16, '11 by mentalhealthRNyeah I gotta agree with 'Elkpark'.......mood is what the patient reports it as. And yes sometimes the patients reported mood is not cungruent with what you are seeing and you would document that.
Here a breakdown that might be helpful for your new nurse......
- Mar 25, '11 by NCindasun21Thanks so much!
- Mar 26, '11 by Whisperayou could chart that "patient seems to be sad/angry/upset/frustrated/whatever as evidenced by" if you're giving your opinion on mood. Otherwise, definitely, mood has to be what the patient says it is.
- Apr 8, '11 by nina539Quote from WhisperaI have to agree that mood is what the pt says it is. I have found in my experience that it can be helpful to chart something like "[patient name] reports they are feeling ..... (sad/angry/upset/frustrated/etc..) and then follow up with something like This writer noted he/she to be .....(whatever you saw) based on ..xy or z.you could chart that "patient seems to be sad/angry/upset/frustrated/whatever as evidenced by" if you're giving your opinion on mood. Otherwise, definitely, mood has to be what the patient says it is.
I think what's important in your documentation is to be specific as to whom the opinion belongs whether it be the pt's or your own. Personally, I tend to go with the more is better idea that to give others reading your documentation a clear view of what occurred.