Improving assessment, verbal& written

[kindgo]

Hello Folks,

I am working in a mental health hospital, we do crisis care. I am a new RN, May 2009, and had a bumpy start with several jobs until this facility called. Been there about 5 months, I love my job, they even made me a charge. However it is still stressful.The real work for most of the patients starts on the outside. I just had my evaluation it was good. My supervisor wants me to improve on my verbal reporting skills. I dont want to open my mouth an sound like I don't know what I am talking about. I understand explaining mood and affect. I just need to feel confident and deliver confident statements in the meetings.

My assessment of the patients needs the correct spin. Sometimes I feel like the doctors and therapist don't consider what the nurses are saying. I need to advocate for the patient and nurses on the unit. I want to be assertive, not passive or aggressive. I feel like I am missing something.

I look and listen to others reports and use what I like and put my own touches on the rest.

But some of the assessements read stuff like, Calm cooperative Mood depressed affect appropriate, interacting well with staff and peers. At times stuff like religously preoccupied. I realize the more exposure I have with different disorders the better it will become. But in the meantime I need more when I go into these meetings. However often there is not more. Any suggestions for improving these areas would be appreciated.

Thanks

[GalRN]

Are you doing admission assessments, triages, or everything indluding the kitchen sink assessments?

If you're doing the whole assessments you absolutely MUST have what I consider the bible of assesment info "Psychitric Interviewing: The Art of Understanding" by Christopher Shea

With all of thise you need a good MSE. It goes in a very specific order- it's pretty much universal. I can't give a phone report without writing one out to get all my thoughts coherent. In fact, when my dad had a psychotic break I went home and wrote one just to clear my head and get things in order. It gave me a clearer piciture of what was going on, as they had all of his sx attributed to the wrong disease.

I did an 18 mo long stint at a VA mental health walk in clinic. You saw a psychiatrist the same day you came in whether or not you'd ever even been to one in the past. The Chief of OP psychiatry was probably the smartest person I've ever met and a great teacher. Every time I got something down pat he had another demand. I thought he was picking on me b/c I was the contractor and I'd never seen him do it to the other nurses. Turned out he thought I was capable of it and the other 2 weren't. Still it kinda sucked when I missed something he wanted and had to go back to the waiting rm, grab the vet, and bring him back in for more detailed questioning.

So, the MSE is what the other ppl in the team need to have the same all the time. Other stuff too, but all the info comes together in that to create a very clear snapshot of the pts thought process and intentions at that moment. You'd need one for all three listed up top.

Basically it is your observations based on certain things you see and ask during an interview. It is likely the most important factor in determining whether a pt goes inpatient or is committed for 72hrs.

I had to write a 1-2hr assessment in narrative form so I'm not used to the regular admit forms where they ask abot mood and affect as it they are the same thing. I got so I had the "normal" one which is quick, and then I had some veerrry interesting ones. Wish I still had my cheat sheets. Not sure wether your pts have the option of going home or not. Mine did and the MD was basing disposition on my facts, and a couple questions of his own.

It goes in this order.

Appeaenece and Behavior:

I start by saying that pt is sitting quietly, or shaking his legs, or pacing in an agitated manner, and cooperatively (or not) answering questions. Whatever they are doing while while they sit with you

If they look older or younger than stated age write that.

Describe exactly what pt is wearing and whether he appears neat and well groomed or is disheveled and malodorous. What do clothes look like, if he is wearing anything unusual or out of place- describe in detail. If he stinks then say he is malodorous and what it smells like if you can identify it.

Maintains good eye contact or not. If not is he looking down, are his eyes darting around the room, closed, tracking something you don't see. Or, he could be making too much eye contact.

Describe any scars or unusual tattoos or piercings.

Mannerisms like twitches, tics also. Posture if it's odd.

Gen'l motor- Exhibits/ does not exhibit psychomotor retardation. If you didn't describe motor bx in gen'l do that here.

Speech/Thought process- normal in rate and volume. Could also be pressured, tangential, have loose asssociations (worse than tangential) and go to flight of ideas which is pressured speech and loose associations.

Latency- does pt answer question after a long pause

Does he start to answer and then stop and stare at something else- thought blocking

Is what he says making sense at all.

Thought content- 1) ruminations (pts don't noticed they're doing it) 2) obsessions (they know it and it usually bugs them) or 3) compulsive bx (counting, checking, anything that is repetitve and that pt is aware of 4)delusions (don't ask they all say no)- that your call based on whether you see a belief that is unshakeable and is usually paraonoid or completely out there. Write exactly what the pt states that is delusional, quotes are best.

Suicidal/Homicidal ideation. You cannot ask too many times. Ask in different ways until you understand if they have thoughts, what they are, have a plan re: how, intend to do it, and if they have taken action to procure items needed to carry it out. If pt has fierarms find out where they are.

Homicidal same stuff.

With both but more so if you are getting positives, you don't believe the pt, and especially if they can leave if the MD so they are safe.

If someone is overwhelmed but not hopeless look for mitigating factors like not wanting to leave children fatherless or it being against religion. This stuff decides whether they are committed. As about previous attemps and assess their lethal potential.

Perception- ask if they are seeing or hearing anything that you can't. Sometimes it's obvious- attending to internal stimuli- if they are looking around or whispering to themselves. If having hallucinations, ask detailed questions. How many voices, what they say, and if they are telling them to do things, and if they can ignore them or will do what they say. If they can even attend to you and answer.

Pts stated mood in quotes

Affect how they seem- sad, grandiose, preoccupied, flat (nothing), blunted, expansive, angry, menacing

Level of consciousness- date day location

Memory- 3 items- and address, and item, and a person. Right away and in 5 min

Have them count backwards from 100 by 7's if they can't do math have WORLD forwards and backwards

Ask about the 3 items.

Ask who the president is and go back naming each one as long as they can

Is judment poor or reliable.

This is the normal version: Pt is sitting quietly in chair and cooperatively answering questions. He is wearing clean khakis, polo shirt and is clean shaven. He looks slightly older than stated age. He maintains good eye and exhibits no psychomotor retardation or tics. His speech is normal in rate and volume with no evidence of formal thought disorder.ie loose associations, thought blocking etc. Denies AH/VH. States passive SI with no specific plan or intent. Denies HI. Does not appear to be attending to internal stimuli. Stated mood is "ok", affect euthymic. He is a + o x 3, and can remember 3 items both times asked. Serial 7's back to 65.

Knows past 4 presidents.

Pt has fair judgment and seems to be a reliable historian.

You get this stuff in order and then look in psych books for the terms. Make a cheat sheet and keep it with you- use it. Go with your gut. You ask most of the questions- any good MD will listen.