PMHN Assessment Guide

PMHN 1: DVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING
Prepared by CHRISTIAN LUTHER FABIA, R.N.,
Professor: DR. EMILIO ALVAREZ, Philippine Colleges of Health & Sciences, Inc., School of Graduate Studies. | 1
Mental Health & Psychiatric Nursing 1:
ADVANCED HEALTH ASSESSMENT IN PSYCHIATRIC & MENTAL HEALTH NURSING
Prepared by
CHRISTIAN LUTHER FABIA, B.S.N.,R.N.
Master of Arts in Nursing
Major in Psychiatric and Mental Health Nursing
DR. EMILIO ALVAREZ
Professor
Philippine Colleges of Health Sciences, Inc., Manila
School of Graduate Studies
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About the cover:
“Introspection” (oil on canvass, 2003)
“The one who has conquered himself is a far greater hero than he who has defeated
a thousand times a thousand men.”
― Gautama Buddha, The Dhammapada: The Sayings of the Buddha
_______________________________________
Self-awareness refers to the ability to recognize the nature of one’s own attitude,
emotions and behavior. It is an important tool in assessing clients who exhibit mental
illness- as one cannot assess another person without introspection.
(THE RATIONALE FOR CHOOSING THE COVER)
A painting by Gurudev Sri Sri Ravi Shankar
(Source: http://artoflivingsblog.com/awareness-the-key-to-happiness/)

- Rationale for Selection of Topics and Organization of Text –
The course title is: Advanced Health Assessment in Psychiatric & Mental Health Nursing. Nurses
in all specialties practice assessment as the first step in the universal approach of problem-solving in
nursing, the nursing process. The application of which in Psychiatric Mental Health Nursing has the same
goal as it has in other areas of nursing.
Though, the goal of the nursing process in this specialty field is not different as mentioned, the process of
assessment is composed of complex concepts the psychiatric mental health nurse must familiarize-
theoretically and clinically. This posted a main challenge in the completion of this material.
The student performed repeated accession and elimination of concepts to finalize the contents which are
deemed significant and consistent with the course title: Advanced Health Assessment in Psychiatric &
Mental Health Nursing.
________________________________________
The text is organized in four parts presenting various approaches in psychiatric assessment. The focus
remained on the basic principles of nursing assessment:
Part 1: Assessment of Psychiatric Mental Health Clients, discusses the basic principles of nursing
assessment; the topic progresses to assessment procedures specific to the specialty field (M.S.E.), an
example was presented to clearly understand its congruence to practice. Related terminologies and
discussion of comorbid problems are important tools in identifying actual and potential health problems
during client assessment.
Part 2: The DSM-IV-TR, An Essential Tool for Assessment and Diagnosis of Psychiatric-Mental
Health Clients, presents vital components of this universal tool in diagnosing mental illnesses.
Part 3: Assessment Factors in Dual Diagnosis, addresses the need to thoroughly assess other equally
significant problems that co-exist with the diagnosed primary mental illness. The co-existence of substance
abuse is the commonest in dual diagnosis.
Part 4: Formulation of Assessment-based Care Plan. The nursing process has been referred to as an
ongoing systematic series of actions, interactions and transactions. Hence, the inclusion of the entire
process is a must to fully appreciate the essentiality of an assessment that is done in congruence with
standards.

- Introduction -
Psychiatric-mental health nursing involves the diagnosis and treatment of human responses to actual or
potential mental health problems. It is a specialized area of nursing practice that uses theories of human
behavior as its scientific framework and requires the purposeful use of self as its art of expression. It is
concerned with promoting optimum health for society. Comprehensive services focus on prevention of
mental illness, health maintenance, management of and referral for mental and physical health problems,
diagnosis and treatment of mental disorders (Haber & Billings, 1993).
Psychiatric nurses must be able to make rapid comprehensive assessments; use effective problem-solving
skills in making complex, clinical decisions; act autonomously as well as collaboratively with other
professionals; be sensitive to issues such as ethical dilemmas, cultural diversity, and access to psychiatric
care for undeserved population; be comfortable working in decentralized settings ; and be sophisticated
about the costs and benefits of providing care within fiscal constraints (ANA, Statement on Psychiatric-Mental Health
Clinical Nursing Practice, 1994,p7).
My definition of psychiatric-mental health nursing is based on my personal experience- which is: “A detour
from the ordinary; a specialty field for nurses who have discovered that they are by nature
empathic. Nurses in this specialty field are professionals who understand the complexes of
human behavior that guides them to respect the uniqueness of every individual. Their ability
to maintain composure in trying situations is almost infinite!”
When I applied at the PCHS Graduate School enrolling in M.A. with Tracks in Psychiatric Mental Health
Nursing- I was asked about my option to pursue the major since I was a lone enrollee in this track. I have
long contemplated pursuing this major considering that this is my area of interest and is consistent with my
professional and academic performances.
With the guidance of my chosen institution to pursue my degree- the PCHS Graduate School, ultimately, I
envision myself as a Forensic Nurse in the future.
The Student
About the Compilation
This material is a compilation of various information on generally acceptable knowledge, concepts, principles, theories and
practices in PSYCHIATRIC AND MENTAL HEALTH NURSING. It adapts contents from various publicly acknowledged publications,
authors, theorists, authorities and practitioners whose works are commonly utilized in the academe and practice, and are frequently-tested
competencies locally and abroad. The works of these authors, theorists, authorities and practitioners are indispensable in learning
PSYCHIATRIC AND MENTAL HEALTH NURSING as they are indispensable in the completeness of this compilation.
Care has been taken to confirm accuracy of the information presented and describes generally accepted practices. However the
student who prepared this material is not responsible for errors or omissions or for any consequences from application of the information in this
compilation.
The primary goal of the student is to familiarize concepts in the subject ADVANCED HEALTH ASSESEMENT IN PSYCHIATRIC
AND MENTAL HEALTH NURSING based on the COURSE DESCRIPTION provided by the PCHS-Graduate School with the
guidance of his Graduate School Professor DR. EMILIO ALVAREZ.
It is not intended for commercial publication and resources were acquired legally. It is his great pleasure that this compilation be reproduced
for reference of other students aiming to thoroughly understand ADVANCED HEALTH ASSESEMENT IN PSYCHIATRIC AND MENTAL
HEALTH NURSING.

- Table of Contents -
Part 1: Assessment of Psychiatric Mental Health Clients, p.4
Overview of Client Assessment
Initial Patient Assessment
Mental Status Examination
Ongoing Assessment
Discussion of Essential Terminologies
Comorbid Problems in Assessing Psychiatric-Mental Health Clients
Part 2: The DSM-IV-TR, p.14
An Essential Tool for Assessment and Diagnosis of Psychiatric-Mental Health Clients
Overview of the DSM-IV TR
Components and Axes of the DSM-IV TR
Major Psycho-Diagnostic Features of the DSM – IV-TR
Differential Diagnosis
Advantages and Disadvantages of utilizing the DSM IV
Socio-cultural Implications
Part 3: Assessment Factors in Dual Diagnosis, p.19
Defining Dual Diagnosis
Dynamics of Dual Diagnosis
Screening and Assessment
Part 4: Formulation of Assessment-based Care Plan, p.22
Nursing Diagnosis
Outcome Identification
Planning and Intervention
Evaluation

Part 1. Assessment of Psychiatric Mental Health Clients
The use of the nursing process has the same goal in psychiatric nursing as it has in other areas of nursing: patient-centered,
goal directed action that facilitates health promotion, primary prevention, treatment and rehabilitation.
“The nursing process is the foundation of clinical decision making and encompasses all significant action taken by nurses in
providing developmentally and culturally relevant psychiatric mental health care to all patients”. (ANA,2000)
Overview of Client Assessment______________________________________________________________
The first step in the nursing process is crucial. Assess the client in a holistic way,
integrating any relevant information about the client’s life, behavior and feelings.
The focus of care, beginning with assessment, is toward the client’s optimum level
of health and independence. (Schultz and Videbeck, 2002)
The assessment phase includes collection of data about a person (child,
adolescent, adult or older client), family or group by methods of observing,
examining and interviewing. The type of assessment depends on the client’s
needs, presenting symptoms and clinical setting (eg.: an adolescent client who
attempts suicide may be assessed in the emergency room, or an older adult may
be assessed in a nursing home to rule out the presence of major depression
secondary to a cerebrovascular accident).
Types of Data
Two types of data are collected:
 Objective Data are measurable and tangible data collected during a physical examination by inspection, palpation,
percussion and auscultation. Vital signs and laboratory results also fall in this category.
 Subjective Data are obtained as the client, family members or significant others provide information spontaneously
during direct questioning or during the health history. Review of past medical history and psychiatric records are
considered to be subjective and it involves interpretation by the nurse.
Types of Assessment
Three kinds of assessment exist:
 Comprehensive Assessment includes data related to the client’s biologic, psychological, cultural, spiritual and social
needs. It is generally completed in collaboration with health care professionals such as physician, psychologists,
neurologist and social worker.
 Focused Assessment includes the collection of specific data regarding a particular problem as determined by the client,
a family member or a crisis situation (eg.: in the event of suicide, the nurse would assess the client’s mood, affect and
behavior; data regarding past attempted suicide would also be collected).
 Screening Assessment includes the use of assessment rating scales to evaluate data regarding a particular problem
(eg.: Hamilton Rating Scale for Depression).
During any assessment, the psychiatric-mental health nurse uses a psychosocial nursing history and assessment tool to obtain
factual information, observe client’s appearance and behavior and evaluate client’s mental or cognitive status.
Initial Patient Assessment_____________________________________________________________
This phase begins on admission to a unit or program with a nurse. Each psychiatric unit, clinic and program has its
own version of an intake or nursing assessment form. Be aware that although, a newly admitted patient may be “medically
cleared,” both physical and mental health assessment should be the focus nursing care.
One study found that complete physical examinations were regularly lacking in newly admitted patients with schizophrenia
(Szpacowicz and Herd, 2008). Complete vitas signs were documented in only 52% of cases in the same study, whereas no vital signs
were recorded in 6% of patients. Typically, the term “medical clearance” indicates that no thorough examination was performed.
A multidisciplinary team including at least the nurse, psychiatrist, the psychologist, social worker, pharmacist is the foundation of
quality care (Zwarensrtein, et al., 2009). A chaplain also might be incuded on the team to add component os a spiritual assessment
(O’Reilly, 2004). The staff nurses uses all information that the team members collect to confirm the patient assessment while
minimizing the need for the patient to repeat information. Because most facilities use intake forms or checklist, the result of the

interviews do not have to be written in narrative forms. Critical facts about the patient should be summarized in an admission note;
the admission note is intended to aid other practitioners who are asked to see the patient.
Mental Status Examination ___________________________________________________________
The mental status examination (MSE) is a very important
component of patient assessment in psychiatric settings.
The MSE focuses on the patient’s current state in terms of thoughts,
feelings and behaviors. The categories of the MSE help organize a
summary of the information gathered during the initial patient
assessment.
Categories Information
General appearance Type, condition and appropriateness of clothing (for age, season, setting), grooming,
cleanliness, physical condition, posture
Behaviors during the
interview
Degree of cooperation, resistance and engagement
Social skills Friendliness, shyness or withdrawal
Amount and type of motor
activity
Psychomotor agitation or retardation, restlessness, tics, tremors, hypervigilance or lack of
activity
Speech patterns Amount, rate, volume, tone, pressured speech, mutism, slurring or stuttering
Degree of concentration Attention span
Orientation To time, place, person, person, situation and level of consciousness
Memory Immediate recall, recent, remote, amnesia and confabulation
Intellectual Functioning Educational level, use of language and knowledge, abstract versus concrete thinking
(proverbs) and calculations (serial sevens)
Affect Labile, blunted, flat, incongruent or inappropriate
Mood Specific moods expressed or observed- euphoria, depression, anxiety, anger,guilt or fear
Thought clarity Coherence, confusion, vagueness
Thought content Helplessness, hopelessness, worthlessness, suicidal thoughts or plans, suspiciousness,
phobias, obsessions, compulsions, preoccupations, poverty of content, denial, hallucinations,
(auditory, visual, tactile, gustatory, olfactory) or delusions (of reference, influence,
persecution, grandeur, religious, nihilistic, somatic)
Insight Degree of awareness of illness, behaviors, problems and their causes
Judgment Soundness of problem solving and decisions
Motivation Degree of motivation for treatment.
Sample Recording of Client, Marlene Aguilar
The nurse introduces himself to Marlene Aguilar and led the way to the office, walking slowly but slightly ahead of the patient.
The patient follows without looking at the nurse. In the office, the nurse sits in a chair at a desk and opens a folder of papers.
The patient sits in a chair at the side of the desk, holding her purse with both hands on her lap.
Nurse Patient Analysis
Verbal Nonverbal Verbal Nonverbal Themes Therapeutic
Techniques
“What do you
prefer to be
called?”
Has pen in hand,
other hand is flat
on desk, is looking
at patient.
(pause)
“Marlene.”
Looking at the
floor.
Content- oriented
to person.
Questioning,
active listening
“Marlene, we
will be better
able to help you
if we know more
about you. What
has happened in
your life
recently?”
(same as above)
(pause) “ I
could not get
out of bed
(pause). I was
so tired.”
Is turning head
slightly, still
looking at the
floor; is not
smiling or
frowning.
Content- describes
fatigue and
effects.
Mood- sadness
Interaction- opens
up with nurse.
Giving information,
questioning
“How long have
you been feeling
Is writing, and
then looking at
“I do not know.
(pause) A week
(same as above) Content- unsure of
time frames,
Placing event in
time or sequence,

so tired?” patient. I guess”. marital separation,
possible
annulment.
active listening
“What happened
a week ago? ”
“I can see this is
difficult for you
to talk about. ”
(pause)
Leans toward
patient. Moves
tissue box.
Looks at patient;
both arms on lap.
(pause) “My
husband
(pause) left.”
“That he was
fed up.”
Tears are in eyes;
tries to open
purse.
Is nodding head;
raises eyes
slightly; is still not
looking at the
nurse. Starts to
cry; gets tissue.
Sobs occasionally.
Mood- sadness,
guilt.
Interaction- in
conflict with
husband; is more
trusting of nurse.
Focusing, using
empathy and
silence,
questioning
“What did he
say when he
left?”
“What did you
say to him?”
Leans toward
patient.
One arm is on lap,
the other on arm
of chair.
(pause) “ That
he wanted an
annulment.”
“I don’t know. I
don’t
remember”.
(pause) “Maybe
I asked him to
stay.”
I crying quietly
Content- difficulty
describing
situations, short-
term memory
disturbance.
Focusing, active
listening
“Then what
happened?”
(same as above) “It’s all blur; I
think I cried all
day.”
(same as above) Mood- sadness,
guilt.
Interactions-
abandonment;
loneliness
Focusing
“Who did you
talk to?”
(same as above) “No one. “
(pause) “My
kids are married
and gone. I just
stayed in bed”
Is the same but
crying less often
Content- did not
ask for help;
avoidance of
divorce issue
Mood-sadness
Interaction-
perceived lack of
support.
Focusing
“When you were
feeling so tired,
did you have
thoughts of
killing
yourself?”
(same as above)
(pause) “I was
so scared of
being alone. I
thought I’d
rather be dead.”
Looks at nurse for
the first time; both
hands are in lap
Content- aware of
tears, suicidal
ideation but no
plan; difficulty
with problem
solving.
Questioning
“How did you
think about
killing
yourself?”
(same as above) “I couldn’t think
of anything, I
didn’t know
what to do.”
Looks at floor
again, fumbles in
purse.
Mood- sadness,
depression.
Interaction-
abandonment;
lack of support;
open with nurse.
Focusing
“Are you still
thinking about
suicide?”
Hands patient a
tissue
“Not really. But
(pause) I still
wish I were
dead. I don’t
know what to
do.”
Blows nose and
then puts hands in
lap, looks at nurse.
Content-
minimizing suicidal
ideation but
ambivalent,
helplessness.
Mood-sadness
Focusing

“While you are
here, we are
going to help
you consider
some options
about what to
do so you won’t
feel so alone
and scared.”
Leans forward.
Looks at patient.
Both hands on lap.
(Silence)
Looks at floor;
crying has
stopped; Looks at
nurse
Interaction- asking
for help
Suggesting
collaboration,
verbalizing
implied, active
listening
“It will help us if
I ask you some
questions.”
Turns back to
papers. Is ready to
write.
Okay. Looks at nurse Giving information
MSE with Marlene Aguilar
General
Appearance
Dressed appropriately for seasons, clothes
are clean but not depressed ; hair is
unwashed and uncombed; slouched
shoulders, pale blank expression.
Memory Immediate recall: Remembers nurse’s
name; Recent: Difficulty organizing
sequence but mostly complete, except for
last week; Remote: Good detail on birth of
children
Behaviors
during the
interview
Degree of cooperation, resistance, and
engagement: slow to respond but
cooperative
Intellectual
Functioning
College education evident in vocabulary;
calculations and proverbs were not done;
abstract thinking evident in discussion of
love and fidelity.
Social skills Withdrawn; no unusual habits; reduced
socialization; poor eye contacts
Affect Blunted
Amount and
type of motor
activity
Slowed; crying at times; no tics or tremors
noted
Mood Depressed; anxiety level is moderate; guilt
and covert anger expressed.
Speech patterns Amount is reduced with slowed rate and soft
tone
Thought clarity Clear; coherent
Degree of
concentration
and attention
span
Decreased concentration; easily distracted by
stimuli; slight shortening of attention span
Thought content Expressing helplessness; hopelessness and
suicidal thoughts without a plan; fears being
alone; no evidence of hallucinations or
delusions
Orientation Aware of person, place and time; responsive Insight Aware of problems in facing divorce but not
yet able to describe factors leading to
separation
Judgment No impairment until last two weeks when she
became unable to make decisions, take
action or seek support
Motivation for
treatment
Wants help with depression, fatigue and
handling divorce; unable to sate what type
of help she needs.
Some patients are too ill to participate in or complete the assessment interview.
In these cases, objective data such as patient behaviors and reports by family members are
used. In some cases, information from staff in the outpatient setting that the patient
attends is available. During the initial assessment, behaviors can be described without
knowing or identifying their causes- for example, anxiety level, degree of withdrawal,
thought disturbances reflected in speech, voice tone and general appearance. Causes and
dynamics can be elicited later to form a strong basis for treatment plan.
Ongoing Assessment _______________________________________________________________
Even when the initial assessment is complete, each encounter with a patient involves a continuing assessment that
might or might not be congruent with the initial assessment. No one acts or feels the same way 24 hours a day, seven
days a week. The ongoing assessment often involves an investigation of patient’s statements and actions at the moment: “You
have been sitting alone for a while?” or “You mentioned being worried; what about?”
When the nurse decides to investigate a patient’s specific behavior, exploring the following might be valuable:
 Context or situation that precipitated the behavior
 Patient’s thoughts at the same time
 Patient’s feelings, then and now
 Whether the behavior makes sense in that context
 Whether the behavior was adaptive or dysfunctional
 How this episode fits with the total picture of the patient
 Whether a change is needed

Discussion of Essential Terminologies ____________________________________________________
 General appearance includes physical characteristics, apparent age, peculiarity of dress, cleanliness and use of
cosmetics. Facial expression is a manner of nonverbal communication in which emotions, feelings and moods are related.
People who are depressed often neglect their personal appearance, appear disheveled, and wear drab looking clothes that
are generally dark in color, reflecting a depressed mood. The facial expression may appear sad, worried, tense, frightened
or distraught. Clients with mania may dress in bizarre or overly colorful outfits, wear heavy layers of cosmetics and don
several pieces of jewelry.
 Affect or Emotional State (the terms affect and emotion are often used interchangeably), the relationship between
affect or emotional state and thought processes is of particular importance.
- Affect is the outward manifestation of a person’s feelings, tone or mood
- Emotional state is expressed objectively on his face, can be widely divergent form what the client says or does;
- Apathy is a term that may be used to describe an individual’s display of lack of feeling, emotion, interest or concern.
- Affective responses may be:
 Appropriate- responses are congruent
 Inappropriate- Discordance or lack of harmony between one’s voice and movements with one’s speech or
verbalized thoughts.
 Labile- Abnormal fluctuation or variability of one’s expressions, such as repeated, rapid or abrupt shifts.
 Blunted- Severe reduction or limitation in the intensity of one’s affective responses to a situation.
 Restricted or constricted- A reduction in one’s expressive range and intensity of affective responses.
 Flat- Absence or near absence of any signs of affective responses, such as an immobile face and
monotonous tone of voice when conversing with others.
Under ordinary circumstances, a person’s affect varies according to the situation or
subject under discussion. The person with emotional conflict may have a persistent
emotional reaction based on this conflict. As the examiner or observer, identify the
abnormal emotional reaction and explore its depth, intensity and persistence. Such as
inquiry could prevent a person who is depressed from attempting suicide.
Helpful techniques in eliciting significant information:
 A lead question such as “What are you feeling?” (may elicit responses such as “angry”, “frustrated”,
“depressed” or “confused”), ask the patient to describe further.
 Observe if the patient’s response constant or fluctuate during the assessment.
 Record a verbatim response to questions concerning client’s mood and note whether an intense emotional
response accompanies the discussion of specific topics.
 Behavior, Attitude and Coping Strategies
Consider the following behavior and attitude:
 Exhibition of strange, threatening, suicidal, self-injurious or violent behavior
 Aggressive behavior may be displayed verbally or physically against self, objects or other people. Are they making efforts to
control their behavior?
 Unusual mannerisms and motor activities- tics, tremors, impaired gait, psychomotor retardation, agitation, pacing (excessively).
 Attitude- friendly, embarrassed, evasive, fearful, negativistic, impulsive- such attitude toward the nurse or other people may
facilitate or impair the assessment process.
 Behavior- overactive or underactive? Purposeful , disorganized or stereotype? Are reactions fairly consistent?
If the client is in contact with reality and able to respond to such a question, ask them how they normally cope with a serious
problem or with high level of stress- responses would help the nurse to assess the client’s present ability to cope and their
judgment. Further assess with the presence of support system or the use of drugs and alcohol to cope (their behavior may be the
result of the absence or inadequate support system).
Paranoid clients may isolate themselves and appear evasive during a conversation and demonstrate negativistic attitude towards
the nurse. The nurse must understand that this is an attempt to protect oneself by maintaining control of a stressful environment.
 Communication and Social Skills
The manner in which the client talks enables the nurse to appreciate difficulties with thought processes. Hence, verbatim
sample of the stream of speech is necessary to be obtained to illustrate pathophysiologic disturbances. Consider the
following while assessing the client’s ability to communicate:

 Coherence
 Flow of speech (logical, illogical, vague, loosely organized)
 Rate of speech (slow, rapid, retarded; responds only when questioned)
 Volume (whisper, soft, loud/shout)
 Delay in answers or break off conversation in the middle of a sentence and refuse to talk further
 Repetition of certain words and phrases
 Do they make up new words that have no meaning to you/ other people
 Use of obscene language
 Numerous topics (jumping from one to another)
 Stutter or regress in speech
 Unusual personality traits interfering with their ability to socialize or adapt with hospitalization- aggressive, domineering, feeling
of rejection, appear to be loner or associate freely with others (social skills).
IMPAIRED COMMUNICATION
Blocking Sudden stoppage in the spontaneous flow or stream of thinking or speaking for no apparent external
or environmental reason; this is associated with preoccupation, delusional thoughts or hallucinations.
Common in clients with schizophrenia experiencing auditory hallucinations.
Circumstantiality Giving too much unnecessary details that delay meeting a goal or stating a point.
Common in clients with mania and some clients with some cognitive disorders (early stage of
dementia or delirium); also in patients who abuse substances.
Flight of ideas Characterized by over-productivity of talk and verbal skipping from one idea to another. Talk is
continuous but ideas are fragmentary.
Eg.: “Do you ever feel blue? Feelings can change from day to day. The days are getting longer.”
Common in manic clients.
Perseveration The person emits the same verbal response to various questions; repetitive motor response to
various stimuli.
Found in client experiencing some cognitive impairment disorders and clients experiencing catatonia.
Vergiberation Meaningless repetition of specific words or phrases.
Observed in clients with cognitive impairment disorders.
Neologism The use of new words or combination of several words coined or self-invented by a person and not
readily understood by others.
Found in clients with certain schizophrenic disorders.
Mutism Refusal to speak even though the person may give indications of being aware of the environment. It
may occur due to conscious or unconscious reasons.
Observed in clients with catatonia schizophrenic disorders; profound depressive disorders; stupors of
organic or psychogenic in origin.
 Content of Thought
Alteration in thought process may be related to a mood disorder (eg.:
depression) or to an organic condition (eg.: dementia).
CONTENT OF THOUGHT
Delusions Fixed false beliefs not true to fact and not ordinarily accepted by other members of the person’s
culture. They cannot be corrected by an appeal to the person experiencing them.
Occur in: various types of psychotic disorders (cognitive impairment and schizophrenia and some
client with affective disorders).
Types of Delusions:
 Reference or persecution- believes that he is object of environmental attention or is being
singled out for harassment
 Alien control- believes that his feelings, thoughts, impulses or actions are controlled by
external source
 Nihilistic- Denies reality or existence of self, part of self or some external object
“I have no head!”
 Self-deprecation- Feeling of unworthiness, ugliness or sinfulness
 Grandeur- Experiences exaggerated ideas of his importance or identity.
 Somatic- Entertains false beliefs pertaining to body image or body function (the client
actually believes that he has cancer, leprosy or some other terminal illness).
Hallucinations Sensory perceptions that occur in the absence of an actual external stimulus. It occurs in clients
with substance-related disorders, schizophrenia and manic disorders.
 Auditory (most common)

 Visual
 Olfactory
 Gustatory
 Tactile
Depersonalization Refers to a feeling of unreality or strangeness concerning self, the environment, or both. Client may
feel they are “going crazy”. Causes include prolonged stress and psychological fatigue, as well as
substance abuse.
Clients with schizophrenia, bipolar disorders and depersonalization disorders have described this
feeling.
Eg.: “Out of body experience” wherein the client view himself from a feet overhead.
Obsessions Insistent thoughts, recognized as arising from the self, absurd and meaningless to the client.
However, they persist despite his endeavors to be rid of them.
Client with obsessive-compulsive typically experience obsessions.
Eg.: “I can’t stop thinking of things”, “I can’t get rid-off these thoughts!”
Compulsions Insistent, repetitive, intrusive and unwanted urges to perform an act contrary to one’s ordinary
wishes or standards.
Client with obsessive-compulsive typically experience obsessions.
Eg.: The repetitive urge to gamble although his wife threatened to divorce him is he does not stop
to.
 Orientation pertains to orientation to time, person and place.
Levels of Orientation and Consciousness
Confusion Disorientation to person, place or time characterized by bewilderment and complexity
Clouding of
consciousness
Disturbance in perception of thought that is slight to moderate in degree, usually due to physical or
chemical factors producing functional impairment of the cerebrum
Stupor A state in which the client does not react or is unaware of his surroundings. The client appears to be
motionless, mute but conscious.
Delirium Confusion accompanied by altered fluctuating consciousness. Disturbance in emotion, thought, and
perception is moderate to severe. Usually associated with infections, toxix states, head trauma and
so forth.
Coma Loss of consciousness
 Memory is the ability to recall past events and experiences.
Categories of Memory
Recent Ability to recall events in the immediate past and for up to 2 weeks previously.
Loss of recent memory may be seen in clients with dementia, delirium or depression.
Long term Ability to recall remote past experiences such as the date and place of birth; names of schools
attended, occupational history and chronologic data regarding previous illness.
Loss of long term memory is usually in due to physiologic disorder resulting in brain dysfunction.
Memory defects may result from lack of attention, difficulty with retention or recall or any combination of this
factors, disorders include:
 Hyperamnesia or an abnormally pronounced memory
 Amnesia or loss of memory
 Paramnesia or falsification of memory
 Intellectual Ability is an indication of a person’s ability to use facts comprehensively. This can be assessed by asking
general information such as the name of the past three presidents, calculate simple mathematical problem or correctly
estimate and form opinions concerning objective matters (Eg.: What would you do if you found a wallet in the hallway?”-
the nurse evaluates reasoning ability and judgment by the response given). Abstract and concrete thinking abilities are
evaluated by asking the client to explain the meaning of proverbs (eg.: “an eye for an eye, a tooth for a tooth”)
 Insight Regarding Illness or Condition
Insight is defined as self-understanding, or the extent of one’s understanding about the origin, nature and mechanisms of one’s
attitudes and behavior. Relevant questions are:
 Does the client consider himself ill?
 Does he understand what is happening?
 Is the illness threatening to him?
Insights into their illness or conditions range from poor to good, depending on the degree of psychopathology present. Insightful
clients are able to identify strengths and weaknesses that may affect their response to treatment.
 Spirituality involves the client’s beliefs, values and religious culture. Spiritual history is important in evaluating whether
these beliefs would help or hinder the client from treatment.

 Does the hospitalize client exhibit spiritual anxiety and verbalize a need to connect with his own spiritual support
system?
 Is the terminally ill client exhibiting a spiritual dilemma regarding the meaning of life and death or the presence of
higher power?
 To what extent the spiritual issues are pertinent to the client’s current situation?
 Are religious beliefs and affiliations served as coping mechanisms?
 Sexuality may be a factor with a client for number of reasons. For example, the client is impotent, may have lost a
sexual partner or may have been a victim of sexual abuse. The age and sex of the nurse may affect the responses given.
Helpful questions that may initiate the topic of sexuality include:
 Does the client express any concerns about sexual identity, activity and function?
 When did these concerns begin?
 Does the client prefer a male or female nurse to discuss these concerns?
 Neurovegetative Changes involves changes in psychophysiologic functions such as sleep patterns, eating patterns,
energy levels, sexual functioning or bowel functioning.
 Depressed clients usually complain of insomnia or hypersomnia, loss or increased appetite, loss of energy,
decreased libido and constipation (all signs of neurovegetative changes).
 Psychotic clients may neglect nutritional intake, appear fatigued, sleep excessively and ignore elimination habits
(sometimes developing fecal impaction).
A simple yet valuable question to ask clients is “Do you have difficulty sleeping
at night or staying awake during the day?” (It has been estimated that as many
as one-third of the clients seen in the primary care setting may experience
occasional difficulties in sleeping and 10% of this may have chronic sleep
problems (Brown, 1999).
Abnormal Sleep Patterns
Insomnia Difficulty initiating or maintaining sleep (symptom with many different causes and occurs in often in
various psychiatric mental health disorders).
Acute/ Primary
Insomnia
Inability to initiate or maintain sleep or nonrestorative sleep for at least 1 month. It is often caused
by emotional or physical discomfort such as chronic stress, hyperarousal, poor sleep hygiene (eg.:
drinking coffee at bedtime), environmental noise or jet lag. It is not due to the direct physiologic
effects of a substance or a general medical condition.
Secondary
Insomnia
Inability to initiate or maintain sleep or nonrestorative sleep due to a psychiatric disorder such as
depression, anxiety or schizophrenia; general medical or neurologic disorder; pain; or substance
abuse.
Comorbid Problems in Assessing Psychiatric-Mental Health Clients________________________________
 Medical Issues
Clients with medical problems commonly present with clinical symptoms of a comorbid psychiatric-mental health disorder.
Thus, communication and collaboration among nurses, doctors and other clinicians is critical. Comorbid depression with various
medical illnesses such as cardiovascular disease, stroke or Parkinson’s disease can impede medical treatment and increase mortality
if the depression is not identified.
 Pain
A major yet largely avoidable health problem is considered a multidimensional experience that potentially affects the
individual physically, emotionally, spiritually and socially. Initially pain is assessed using pain rating scale appropriate to the client’s
age and ability to communicate. This baseline pain assessment is used for comparison with all future assessments. Self-report of
pain is the most reliable and valid pain assessment tool. If the client is unable to communicate, data are obtained by observing
behavior, obtaining proxy reports from family or significant others, or by documentation of physiologic parameters.
 Physiologic Reponses to Medication
It is important to assess the potential adverse effects of various medications that could precipitate client’s emotions,
behavior or mental status. It requires that a nurse should carefully recognize potential or present effects of the client’s drug therapy
(Eg.: A patient diagnosed with Parkinson’s disease with comorbid depression on carbidopa (Sinemet) for 3 months visits the clinic
for supportive therapy complains of confusion, disorientation and visual hallucinations. After reassessing the client to rule out
clinical symptoms of clinical depression, the nurse educates the client about the potential side effects of carbidopa and documents
the patient’s physiologic responses to medication).

Part 2
The DSM-IV-TR:
An Essential Tool for Assessment and Diagnosis of Psychiatric-Mental Health Clients
Overview of the DSM-IV TR___________________________________________________________________
The Diagnostic and Statistical Manual of Mental Disorders (DSM) is the
standard for classifying mental disorders that are used by mental health
professionals in the United States and is adopted in various parts of the world. It is
intended to be applicable in a wide variety of contexts and used by clinicians and
researchers of many different orientations (For example; biological, psychodynamic,
cognitive, behavioral, interpersonal, family/systems).
The DSM IV has been designed for use across settings such as inpatient, outpatient,
partial hospitalization, consultation-liaison, clinic, private practice and primary care.
Professionals that use the DSM diagnosis are psychiatrists, psychologists, social
workers, nurses, occupational and rehabilitation therapists, counselors and other
health and mental health professionals. The DSM is also a necessary tool for
collecting and communicating accurate public health statistics.
Components and Axes of the DSM-IV TR_________________________________________________________
The DSM consists of three major components: the diagnostic classification, the diagnostic criteria sets and the descriptive
text.
 Diagnostic Classification
The diagnostic classification is the list of the mental disorders that are officially part of the DSM system. Making a DSM
diagnosis consists of selecting those disorders from the classification that best reflects the signs and symptoms that are afflicting
the individual being evaluated. Associated with each diagnostic label is a diagnostic code, which is used primarily by institutions and
agencies for data collection and billing purposes. These diagnostic codes are derived from the coding system used by all health care
professionals in the United States, known as the ICD-9-CM.
 Diagnostic Criteria
Each disorder included in the DSM includes a set of diagnostic criteria including symptoms that are present and for how long.
These criteria called inclusion criteria as well as those symptoms that must not be present called exclusion criteria qualify and
individual for a particular diagnosis.
Many users of the DSM find these diagnostic criteria useful because they provide a compact description of each disorder. Use of this
diagnostic criterion has been shown to increase diagnostic reliability and increase the likelihood that different individuals will assign
the same diagnosis). It is important to remember that these criteria are meant to be used as a guideline by an informed clinician.
 Descriptive Text
The third component of the DSM is the descriptive text that accompanies each disorder. The text of the DSM-IV systematically
describes each disorder under the following headings: Diagnostic Features; Subtypes and/or Specifiers; Recording Procedures;
Associated Features and Disorders; Specific Culture, Age, and Gender Features; Prevalence; Course; Familial Pattern; and
Differential Diagnosis.
The DSM uses a multi-axial approach to diagnosing because rarely do other factors in a person’s life not impact their
mental health. It assesses five dimensions.
The DSM Multi-Axial System
Axis I Clinical Syndromes
 This is what is thought of as the diagnosis (e.g. depression, schizophrenia, social phobia); Clinical Disorders and ther
conditions that may be a focus of clinical attention.
 More Examples- Delirium due to a general medical condition; Generalized anxiety disorder; Noncompliance with

treatment; Malingering; Identity problem
Axis II Developmental and Personality Disorders
 Developmental disorders including autism, mental retardation and disorders which are typically first evident in
childhood.
 Personality disorders which are clinical syndromes having more long lasting symptoms and encompass the individual’s
way of interacting with the world. They include Paranoid, Antisocial and Borderline Personality Disorders.
Axis III Physical Conditions which play a role in the development, continuance, or exacerbation of Axis I and II Disorders
 Physical conditions such as brain injury or HIV/AIDS that can result in symptoms of mental illness are included here;
Concussion, medical-induced postural tremor; congestive heart failure
Axis IV Severity of Psychosocial Stressors
 Events in a person’s life, such as death of a loved one, starting a new job, college, unemployment, and even marriage
can impact the disorders listed in Axis I and II. These events are both listed and rated for this axis.
 Problems are grouped into:
- Primary support group
- Social environment
- Educational
- Occupational
- Housing
- Economic access to healthcare services
- Interaction with the legal system/ crime
- Other psychosocial and environmental problems
Axis V Highest Level of Functioning
 On the final axis, the clinician rates the person’s level of functioning both at the present time and the
highest level within the past year. This helps the clinician understand how the above four axes are affecting the
person and what type of changes could be expected.
 The GARF Scale can be used to indicate an overall judgment of the functioning of a family or other ongoing
relationship on a hypothetical continuum ranging from competent, optimal relational functioning to a disrupted,
dysfunctional relationship (APA, 2000).
Global Assessment of Relational Functioning (GARF) Scale:
1. GARF of 81-100 Overall: The individual is functioning satisfactorily from self- report of participants and from
perspective of observers. There is a situationally appropriate, optimistic atmosphere in the family. A wide range
of feelings are expressed freely and managed within the family unit. There is a general feeling of warmth,
caring, and a sharing of values among all family members. Sexual relations of adult members are satisfactory
(APA, 2000).
2. GARF of 61-80 Overall: Functioning of the individual is somewhat unsatisfactory. Over a period of time, many
but not all difficulties are resolved without complaints. A range of feelings are expressed but instances of
emotional blocking or tension is evident. Warm and caring feelings are present but are marred by family
members irritability and frustrations. Sexual activity of adult members may be reduced or problematic (APA,
2000).
3. GARF of 41-60 Overall: Relational unit has occasional times of satisfying and competent functioning together,
but clearly the relationship is dysfunctional. Unsatisfying relationships tend to predominate. Pain and ineffective
anger or emotional complications interfere with family enjoyment. Although there is somewarmth and support
for members, it is usually unequally distributed. Troublesome sexual difficulties between adults are often present
(APA, 2000).
4. GARF of 21-40 Overall: Relational unit is seriously dysfunctional; forms and time periods of satisfactory
relating are rare. There are infrequent periods of enjoyment of life together; frequent distancing or open hostility
reflects conflicts that remain unresolved and painful. Sexual dysfunction among adults is common (APA, 2000).
5. GARF of 1-20 Overall: Relational unit is too dysfunctional to retain continuity of contact or attachment.
Despair and cynicism are pervasive; there is little attention to the emotional needs of others; there is no sense of
attachment, commitment, or concern about one another’s welfare (APA, 2000).
Major Psycho-Diagnostic Features of the DSM – IV-TR________________________________________________
According to the DSM-IV, mental disorders are conceptualized as clinically significant behavioral or psychological syndromes or
patterns that occur in a “person” and are associated with “distress” (a painful symptom) or “disability” (impairment in one or more
important areas of functioning). In addition, the syndrome or pattern must not be an acceptable response to a particular event
(APA, 2000).
The DSM system can be difficult to interpret for those with limited clinical expertise or personal familiarity with mental disorders. It
is however relatively easy for experienced counselors to learn. Each DSM- IV contains specific diagnostic criteria, the essential
features and clinical information associated with the disorder, as well as differential diagnostic considerations. Information
concerning diagnostic and associated features, culture, age, gender characteristics, prevalence, incidence, course and complications
of the disorder, familial pattern and differential diagnosis are included. Many diagnoses require symptom severity ratings (mild,
moderate, severe) and information about the current state of the problem (e.g. partial, or full remission).

The DSM-IV contains fifteen categories of mental disorders:
1. Disorders Usually First Diagnosed in Infancy, Childhood or Adolescence – focuses on developmental disorders and other
childhood difficulties.
2. Delirium Dementia, Amnestic and other Cognitive Disorders – this includes Alzheimer’s conditions and Vascular Dementia.
3. Mental Disorders Due to a General Medical Condition – this includes anxiety and mood difficulties as well as personality
change due to physical complications.
4. Substance Related Disorders – consist of drug and alcohol abuse and dependence.
5. Schizophrenia and Other Psychotic Disorders – this is a continuum of difficulties that stress lack of contact with reality as
well as Delusional Disorders.
6. Mood Disorders and Anxiety Disorders – includes major Depression and Posttraumatic Stress Disorder are featured
diagnoses.
7. Somatoform Disorders
8. Factitious Disorders
9. Dissociative Disorders
10. Sexual and Gender Identity Disorders
11. Eating Disorders
12. Sleep Disorders
13. Impulse Control Disorders
14. Adjustment Disorders
15. Personality Disorders
Groupings of Personality Disorders
Cluster A
Is characterized by limited range of emotion in social interactions and form few if any close
relationships with others. They are generally suspicious others.
1. Paranoid:
 .5% -2.5% of the general population.
 10% - 30% reside in residential settings.
 2%-10% participate in outpatient mental health settings.
2. Schizoid:
 This is uncommon in clinical settings
3. Schizotypal:
 3% of the general population
Cluster B
Characterized by violating the boundaries of others.
1. Antisocial:
 3% of males and 1% of females in community samples.
 Up to 30% in substance abuse settings.
2. Borderline:
 10% participate in outpatient programs
 20% reside in residential settings
3. Histrionic:
 2%-3% of the general population
 10%-15% participate in both residential and outpatient settings
4. Narcissistic:
 2%-16% of the clinical populations
Cluster C Characterized by being socially inhibited, usually feel inadequate and are overly sensitive to
criticism.
1. Avoidant:
 .5%-1% of the general population
 10% of the clinical populations
2. Dependent
 unknown
3. Obsessive/compulsive
 3%-10% of the clinical populations
Source: DSM-IV-TR for Clinicians: Accurate Diagnosis and Effective Treatment Planning, (2006).

Differential Diagnosis______________________________________________________________________
The key to accurate treatment is for the clinician to come up with the
accurate differential diagnosis. There are four steps to take that will
ensure accuracy:
Step 1:
• Is the presenting symptom real?
There are two conditions in the DSM –IV –TR that are characterized by conscious feigning:
 Malingering is a behavior aimed at the achievement of a clear goal such as insurance compensations, avoiding legal or
military responsibilities or obtaining drugs.
 Factitious diagnosis is a behavior that lacks a clear external gain
Step 2:
• Rule out Substance Etiology
Virtually all psychiatric presentations that are encountered by clinicians can be caused by substances that act on the central nervous
system. Failure to recognize substance etiology is a leading cause of diagnostic errors. The presence of substance use and
psychopathology does not establish a cause and effect relationship.
Three possible connections must be explored:
 Do the psychiatric symptoms result from the direct effects of the substance on the central nervous system?
 Is the substance use a consequence of having a primary psychiatric disorder (e.g. using alcohol or drugs to manage the
symptoms)?
 Are the psychiatric symptoms and the substance using independent?
When diagnosing a substance induced disorder, a clinician must determine
whether there is a close relationship between the substance use and
psychiatric symptoms. The clinician must also consider the likelihood that the
particular pattern of substance use can result in the observed psychiatric symptoms.
Finally, it should also be considered whether or not there is a better alternative
explanation (i.e., non-substance induced) for the clinical picture.
Substance withdrawal must also be considered. The DSM-IV-TR criteria for substance induced suggest that psychiatric symptoms
be attributed to the substance use if they remit within a month of the cessation of acute intoxication, withdrawal or medication use.
There has been significant debate regarding the four week time limit.
Step 3:
• Rule out a Disorder due to a General Medical Condition.
Any psychiatric presentation can be caused by the direct physiological effects of a general medical condition.
There are five possible relationships to explore:
 Whether the general medical condition causes the psychiatric symptoms through a direct physiological effect on the brain.
 Whether the general medical condition causes psychiatric symptoms through a psychological mechanism (e.g., depressive symptoms in
response to being diagnosed with cancer – diagnosed as Major Depressive Disorder Or Adjustment Disorder.
 Whether the medication taken for a general medical condition causes the psychiatric symptom.
 Whether or not the psychiatric symptoms cause or adversely affect the general medical condition
 Whether or not the psychiatric symptoms and general medical condition are coincidental.
There are two considerations when ruling out medical conditions:
 The temporal relationship: Do the psychiatric symptoms begin following the onset of the general medical condition, vary in severity with
the severity of the general medical condition and disappear when the general medical conditions resolves?
 The Atypical Course is the next consideration to look at: If the psychiatric presentation is atypical in symptom pattern, age at onset or
course.

Step 4:
• Determine the Specific Primary Disorder(s)
A clinician can utilize the decision trees in the DSM-IV along with the diagnostic Criteria Charts.
The DSM-IV is not the only psych-diagnostic nomenclature in existence, but it is the most popular. An up-to-date understanding of this
diagnostic system and its implications in counseling is imperative for an individual to be effective and ethical in his/her delivery of professional
mental health counseling services.
Advantages and Disadvantages of utilizing the DSM IV____________________________________________
Assigning a diagnosis to a client remains uncomfortable for many counselors. The disadvantages associated with using the
DSM have included the promotion of a mechanistic approach to mental disorder assessment. There is a false
impression that the understanding of mental disorders is more advanced than is actually the case. There is an excessive focus on
the signs and symptoms of mental disorders to the exclusion of a more in depth understanding of the client’s problems including
human development.
Conversely, advantages to implementing the DSM include the development of a common language for discussing
diagnoses. There has been an increase inattention to behaviors and the facilitation of the overall learning of psychopathology.
Seligman (1990) has indicated that knowledge of diagnosis is important for counselors so that they may provide a diagnosis for
clients with insurance coverage and inform clients if their counseling will be covered by medical insurance. In addition, the DSM
diagnosis assists with accountability, record keeping, treatment planning, communication with other helping professionals and
identification of client with issues beyond areas of expertise.
Socio-cultural Implications________________________________________________________________
Professional counselors utilizing DSM-IV diagnoses yield sizable power that can be interpreted as oppressive to some groups of
people. Psycho-diagnosis therefore is reliant on ethno-cultural and linguistic sensitivity (Malgady, Rogler & Constantino, 1987). Clients of
lower socioeconomic class may experience, define and manifest mental disorders differently from middle and upper class clients.
The DSM’s lack of focus on the problematic features of a social context may be perpetuating the oppression
of certain groups of people (e.g., women).
Gender and race of the clinician also have been found to impact an accurate psych- diagnosis (Loring & Powell, 1988). Counselors using
the DSM-IV will need to be aware of the implications associated with its use as well as the impact a diagnosis may have on a
client’s treatment both within and outside of the counseling process.
Religion is often at odds with the existence of mental disorders. Some religions prohibit or discourage psychotherapy. Some
religions prohibit or discourage psychiatric medication. Religious ideation is at times prevalent in psychotic delusions.

Part 3:
Assessment Factors in Dual Diagnosis
“Drug addicts or substance abusers have dual diagnosis: substance addiction or substance dependence, and psychiatric disorder
whether it’s depression or anxiety. These patients become drug addicts because they are self-medicating.”
“Some of the statistics in the hospital would say that yes, they started as saying they have specific psychiatric disorder but they end
up being addicts.”
Dr. Noel Reyes
Psychiatrist, National Center for Mental Health
(In an interview by Flores published at Philippine Star, 2007)
Traditional psychiatric treatment has divided patients into distinct categories based on the belief that one type of
illness or disorder is primary or more urgent than another. Historically, patients were categorized as having either a mental
illness or a substance abuse or dependency problem and received separate treatment for each disorder. The mental health
community has now recognized and focused increased attention on the needs and appropriate treatment of patients with
dual diagnosis and co-occuring disorders.
The complexity of needs, problems, and multiple impairments in patients with co-occuring disorders requires a comprehensive
assessment, therapeutic treatment approach and individual case management. Patients with psychiatric illnesses and substance
abuse or dependency problems have poor treatment outcomes with high rates of relapse, resulting in high costs in multiple
settings.
Defining Dual Diagnosis__________________________________________________________________
The term dual diagnosis refers to the presence of at least one
psychiatric disorder in addition to a substance abuse or dependency
problem. The psychiatric disorder might be a mental illness or a personality
disorder. An example of a person with dual diagnosis is an individual with
chronic schizophrenia and alcohol abuse. Another example is a patient with
heroin dependency and antisocial personality disorder. Considering the number
of axis I and axis II diagnoses, a multiple combination is possible. Therefore
patients with co-occuring disorders or disorders that occur at the same time
represent a heterogenous group. Research studies indicate that about 49% to
60% of patients in treatment settings have co-occuring disorders and are 3-4
times more likely to be hospitalized than those with mental illness alone
(Dilonardo et al., 2008; Havassy et al., 2009).
Dynamics of Dual Diagnosis ______________________________________________________________
One issue that mental health professionals traditionally deal with is which comes first- the mental illness or
the substance abuse problem. Consider the following examples of dual diagnoses:
Examples of Dual Diagnoses
Axis Diagnosis
I Schizophrenia
Alcohol Abuse
I
II
Cocaine Abuse
Antisocial Personality Disorder
I Major Depression
Anxiolytic Dependency
I
II
Major Depression
Marijuana Abuse
Borderline Personality Disorder

From the perspective that mental illness occurred first, many reasons might account for the
development of a substance abuse problem. As is true for mental illnesses, heredity, environmental and
biologic factors might predispose an individual to problems with substances. Some people might be
predisposed to develop both a mental illness and a substance abuse problem.
From the idea that substance abuse precedes mental illness, it follows that brain chemistry
can be altered- that is, neurotransmitter imbalance or depletion can occur. Chemicals can induce
acute and chronic psychiatric problems. Substance-induced psychosis, schizophrenia, depression and mania
can occur in vulnerable individuals. Substance abuse can also lead to feelings of guilt, depression, and
altered self-esteem. Repeated stimulant use can alter the dopamine system, and alcohol dependence can
increase the positive symptoms of schizophrenia (Addington and Addington, 2001; Littrell and Littrell, 2009).
Environmental and psychological factors, such as poor social and educational functioning, boredom,
dysphoria, unemployment and poverty are contributing factors leading to the risk of substance abuse.
Individuals with severe and persistent mental illness such as schizophrenia experience adverse
consequences with even a modest use of alcohol and psychoactive drugs (Green et al, 2007).Specific drugs are
abused based on market forces and use begins prior to development of psychosis. In the Philippines, it has
been noted by the Dangerous Drugs Board that eight million Filipinos are drug users.
 Self-medicating with alcohol or drugs can help patients with psychotic symptoms feel better and less
anxious; using substance do not result in uncomfortable side effects as compared to antipsychotics;
but results in worsening of symptoms after the effects of alcohol or drug have worn-off.
 Social acceptance, feeling of autonomy or power, problems and issue are avoided and that a higher
degree of self-esteem and control are felt when drink alcohol or use substance. Studies have shown
that for individual with severe mental illness, substance use offers an opportunity to socialize, which
can be a prime reason for use (Drake et al., 2002).
 Individuals with schizophrenia have reported using alcohol, cannabis and cocaine to bdecrease
depression, anxiety and side effects of antipsychotic medications (Addington and Addington, 2001).
 Individuals with depression sometimes use stimulants to boost their energy so thay can work and
care for their families.
 Substance abuse issues are often present in the population of individuals with personality disorders.
Some traits or behaviors of substance abusers are the same as those with personality disorders.
Regardless of which disorder comes first, the existence of a
substance problem, mental illness or personality disorder complicates
diagnosis and treatment, prolongs rehabilitation, in increase the
incidence of relapse, associated with violence, homelessness and in
some cases contracting HIV and Hepatitis infection (Drake et al, 2002).
The complexity of these patient’s problems requires skills in assessment to be able to apply a
holistic and integrated approach for treatment.
Dual Diagnosis: Screening and Assessment____________________________________________________
The DSM-IV TR is a standard assessment tool in diagnosing patients with Dual Diagnosis. However, as
mentioned in earlier discussion, the DSM-IV TR is not the only method in defining and classifying mental
health problems. The nurses’ skills in assessment in conjunction with his professional and personal
attributes with good communication techniques play a major role in the process of assessment.
Irrespective of the service to which problems are ﬁrst presented, screening and assessment is fundamental
to achieving better diagnostic outcomes. Considerations include; the experience of the assessment, the

environment of the assessment, a high index of suspicion, a robust assessment process that includes a
thorough history, and the use of appropriate screening and assessment tools in a multi-disciplinary context.
Without rigorous detection, problems will be missed or attributed inappropriately, and may result in the
subsequent treatment or care response being inadequate, incorrect, or even neglectful.
Nurses who perform screening and assessment must seek to
understand the patient’s story and perspective on their illness,
and should not exclude their family members or significant
others. Although screening and assessment may incorporate
standardized tools and involve some medical investigations
(blood, urine, and hair analysis), an evaluation of
occupational capacity, social or relationship functioning
and quality of life are also important in determining the
client’s life experience.
Assessment is likely to take place over the mid to long term and thus require regular monitoring as well as
continual interaction and collaboration between colleagues working in allied services. The use of common
protocols and processes is desirable because it avoids the unnecessary repetition of multiple assessments,
which patients may ﬁnd exhausting and may lead to resistance to further assessment. It also helps to
establish common understanding of terminology, deﬁnitions, approaches, interventions and outcome
expectations.

Part 4
Formulation of Assessment-based Care Plan
Nursing Diagnosis___________________________________________________________
A nursing diagnosis is the identification of patient’s problems based on conclusions about the dynamics evident in verbalizations and
behavior. It is directly related to the content, mood and interaction themes described in the previous discussions.
Emergency behaviors (eg.: suicidal or homicidal ideas or attempts, aggression, destructive behaviors, risk of arson or escape) are
given priority in establishing no-harm agreements with patients. Suicidal intent should be regularly assessed, whether or not a
patient agrees to a no-harm contract (Lynch, et al, 2008). Regardless of format or style of the nursing diagnosis in a particular setting,
the diagnosis should be specific and indicate a desired outcome for the patient.
The NANDA International diagnosis is the most widely accepted and used nursing diagnoses. It suggests a statement format
that has the following three components:
 Risk for actual problems
 Contributing, causative or etiologic factors
 Defining characteristic or behavioral outcome
It is typically written as follows:
 (Problem) related to;
 (Contributing factor) as evidenced by;
 (Behavioral outcome
Eg.: “Anxiety, moderate, related to marital problems as evidenced by ineffective problem solving.”
 Actual or potential problems are identified from the list approved by NANDA International
 Contributing or causative factors can include stressors, losses, past experiences, developmental issues, environmental
circumstances, relationship issues, and self-perceptions.
 Defining characteristics or behavioral outcomes are the very verbal and nonverbal cues that reflect the patient’s
actual or potential problems.
 These maladaptive behaviors or cues are the focus of the nursing interventions- behaviors that it would be helpful to
change.
 Being specific when describing the dysfunctional behaviors or cues is useful in providing direction for selecting
desirable or adaptive behaviors identified in the patient’s desired outcomes.
 It does not include medical diagnosis in any of the three parts of diagnostic statement.
Outcome Identification_________________________________________________________
A goal or outcome specifies an adaptive behavior to replace one that is dysfunctional. Expecting patients to change a negative self-
image to a positive self-image during a short inpatient stay or outpatient program is unrealistic. A more realistic behavioral goal
would be to ask patients to write a list of their strengths, abilities and positive qualities. This goal is achievable and measurable.
 Short term goals or outcomes are those achievable in perhaps 4-6 days for hospitalized patients and perhaps
somewhat longer for patients in other settings.
 Long term goals or outcomes relate to issues that require follow-up counseling after discharge to another type of
service within the continuum of care, example;
Goal Statement
Short-term Identify difficulties with intimate relationships
Long-term Practice how to respond to anxiety-provoking dating situations; thus, by increasing awareness
of fears, the patient might be better able to address these types of situations.
 In establishing goals and outcomes with a patient (collaboration), the nurse must understand the problems the patient
wants to address and the goals the patient wants to achieve.
 Patient desire and motivation play a major role in attaining outcomes (Atreja et al., 2005). Patient support systems and
resources might also facilitate outcome achievement (Mc Bride, 2000).

Planning and Intervention_______________________________________________________
Nursing Care Plans
Nursing staff, on units or in programs, often develop standardized care plans with expected outcomes for certain types of patient
problems. These care plans might focus on psychiatric diagnoses (eg.: major depression) or more specific problems (eg.: self-
mutilation). The initial nursing care plan might be updated at any time but begins with one or two behavior-oriented problems to be
addressed immediately (eg.: suicide, aggression, arson, escape, withdrawal or isolation, delusion, hallucinations, impulsive or
compulsive acts, suspiciousness, uncooperativeness, or altered though processes).
For example:
 A patient who has suicidal ideation (problem) would be expected to sign a no-harm agreement (outcome) within 24 hours
(time constraint) and to verbalize a plan for dealing with suicidal ideation (outcome) by 3 days of admission (time
constraint).
 Related nursing interventions would include (1) an agreement with the patient for safety, (2) removal of dangerous
objects from the patient and the patient’s room, and (3) assessment for suicidal ideation during every shift.
Given the current managed care climate, a goal of standardized care plans is to expedite treatment activities to achieve patient
outcomes in a cost-effective manner. Nursing interventions focus particularly on “safety, structure, support and symptom
management” (Delaney et al., 2000). However, the nurse must remember that each patient is an individual, even some of the patient’s
problems fit into a standardized plan. A patient’s unique problems and needs must not be ignored when formulating the plan of
care (Benner, 2000).
Historically, psychiatric nursing interventions involve few hands-on activities other than minor treatments, monitoring vital signs and
giving medications. However, there is an increasing recognition of the chronic disease that many people who live with mental illness
experience because these people tend to die from chronic diseases many years earlier than their nonpsychiatry ill counterparts.
Medical conditions are undertreated in the psychiatry settings; Psychiatric nurses must use both interpersonal skills as well as
health assessment skills on behalf of their patients.
Nevertheless, the focus of psychiatric nursing is often on verbal strategies (as shown in the previous example of recording and MSE
with Mrs. Aguilar) that are used to guide patient in exploring and solving problems for themselves and achieving desired outcomes.
Psychiatric nurses are primarily facilitators and educators. Solving problems and changing behaviors are never quite easy as they
sound. Patients might need help with developing specific and concrete plans for reaching their goals.
Progress Notes and Shift Reports
The style of charting progress notes (written or electronic) varies in each setting, but the components are basically the same: the
patient’s statements and the nurse’s observation, analyses and plans. Charting and shift reports are important ways of
communicating with team members to ensure continuity of care. These reports are also ways the short term and long term
outcomes. Patients must also be kept informed of their progress towards their goals. The nurse must remember that the entire
chart is a legal document subject to review by peer review agencies, quality improvement staff and accreditation bodies (Oermann and
Huber, 1999).
Progress Note Components
Subjective content The patient’s statements about his own thoughts, feelings, behaviors and problems.
Objective content The nurse’s observations or measurements, such as the patient’s appearance, nonverbal
behavior and vital signs.
Analysis or
conclusions
The nurse’s impressions of what the patient is experiencing or demonstrating in
behavioral or descriptive terms (not medical diagnosis); defenses, mood and issues are
identified; depressed mood and paranoid ideas can be discussed, but “depression” and
“paranoia” are not listed as illnesses.; conclusions about changes (regression or
progression) in the patient and medication responses are described.
Plans Actions that nurses or other team members can take to intervene with the problems
described in the progress note.

Sample Progress Note for Marlene Aguilar
Date and Time: 08/26/2013 0500
Subjective content Patient states that she is a little less tired. States she is
still unsure what led to the separation and cannot face living
alone. Still have thoughts of suicide but no plan: “I still wish
I were dead”. Verbalizes that she still does not know what to do
about impending divorce and being alone in the future. Said she
called her employer to extend her sick leave and called her son
and daughter who will visit this evening.
Objective content Exhibits blunted, depressed affect, slowed motor activity and
speech. Attended one therapeutic group and a craft activity, but
only one participated briefly. Napped for only 2 hours this
shift.
Analysis or
conclusions
Patient cannot describe her thoughts and feelings, but guilt,
helpless ness and hopelessness are evident. Anger is barely
evident at this point. Suicidal but lacks energy to plan.
Support is available from her adult children.
Plans  Approach and seat with patient frequently.
 Encourage verbalization of feelings especially anger.
 Monitor energy level and suicidal ideation
 Continue medication as ordered
 Encourage participation in group meetings and activities.
Evaluation _________________________________________________________________
Patient Progress
The more realistic and measurable are the goals, the greater is the likehood that patients and nurses will have a sense of progress.
A major problem arises with evaluating care in psychiatric nursing when too much change is expected too soon. When the patient
or nurse becomes aware of a lack of progress towards goals, evaluation should lead to reassessment. Using the nursing process
leads to reformulation of the nursing diagnoses and the establishment of more realistic, appropriate outcomes. Even when short
term goals are met, patients have other unsolved problems. If the short term goals were related to learning better skills (eg.:
communication, problem solving , social skills), then patient can continue to progress after discharge.
Evaluating patient progress is important in determining patient referrals to other levels of care and supervision within the
continuum of care. The issue of prior nonadherence with medications and treatments needs to be addressed early in the admission.
This might affect the type of referrals made for outpatient referral (Julius et al, 2009). In addition to evaluating the progress notes of
patients, nurses evaluate the quality of interventions and their professional behaviors.
Discharge Summaries
Nurses today are more proactive in writing transfer or discharge summaries and discharge instructions that are given to patients.
Summaries usually identify outcomes that must still be addressed. The information included in the discharge summary are as
follows:
 Medications (dosages and time)
 Follow-up appointments (with dates and time)
 Referrals to other services in the continuum of care
It is important to assess the patient’s ability to read and understand the discharge instructions.
Process Recordings
Process recordings are tools for the nurses to learn about working with patients effectively. It is a way to gain deeper
understanding of the communication process (eg.: rehabilitation setting in which communication is impaired by stroke). The use of
communication skills via process recordings emphasize as a means of helping patient learn and solve problems.
It provides a means of assessing and analyzing communication skills, identifying patient themes and evaluating the effectiveness of
the interventions (Festa et al., 2007). Audiotape and videotape recordings are more accurate compared with written reports but

resources cannot always afford for these media. In most settings, written process recordings is utilized which might begin with
notes taken during the interview or might be completely assembled by recall afterward.
A process recording is a record of encounter with a patient that is verbatim as possible. The recording generally includes the
nonverbal behaviors of the nurse and the patient, as well as the verbal interaction. Analysis of content, mood and interaction
themes might be included next to each written statement or summarized at the end of the process recording. It may be analyzed
by the nurses or shared with a fellow colleague who can provide constructive feedback on problem areas and strategies for
improvement (see the sample process recording for Marlene Aguilar in Part 1).
Sample Care Plan
Name: MARLENE AGUILAR
Admission Date: 25 August 2013
DSM-IV-TR Diagnosis: Depressive episode
Assessment Areas of Strength: Has family who cares; had good work record; has asked for help; is thinking
abstractly
Problems: Is unable to get out of bed and care for self; has suicidal thoughts but no plan; exhibits
decreased socialization and support; impending annulment
Diagnosis  Risk for suicide related to impending annulment and wish to be dead
 Anxiety related to anger and fear of living alone, as evidenced by expressing helplessness
 Hopelessness related to lowered self-esteem, as evidenced by not caring for self
Outcomes Short term goals
 Patient will agree to talk with staff when she thinks wanting to be dead
 Patient will verbally express anger at husband and situation
 Patient will contact friend, employer and children for assistance
Long term goals
 Patient will state where will she live after discharge
 Patient will verbalize confidence in her ability to support self
 Patient will describe resources available to her, especially if she becomes suicidal again
Planning/
Interventions
Nurse-patient relationship
 Initiate suicide precaution as a nursing measure; monitor energy level and suicidal ideas;
encourage activities of daily living; teach relaxation techniques; offer support as feelings
are expressed; reinforce strengths; assist in compiling a list of resources.
Psychopharmacology
 Fluoxetine 20 mg PO every morning
Milieu Management
 Encourage patient to stay out of room; request patient attendance at grief and loss, self-
esteem, assertiveness, problem-solving and recreational groups.
Evaluation Patient will stay with daughter after discharge; patient called employer and request extended sick
leave
Referral Patient made appointment for outpatient counseling; patient has information on annulment
recovery group and a 24-hour crisis and suicide hotline.
_____________________________________________________________________________

References:
Textbooks:
Basic Concepts of Psychiatric- Mental Health Nursing; Author- Louise Rebraca Shives, 6th
Edition
Keltner’s Psychiatric Nursing; Authors- Norman L. Keltner, Carol E. Bostrom, Teena M. McGuines
Psychiatric-Mental Health Nursing, 4th
Ed.; Author- Sheila L. Videbeck
Journals:
WHO-AIMS/ DOH report on mental health system in the Philippines (2006), Manila, Department of Health
APA (2000); DSM-TR (4TH
ED.); Washington DC, APA
Internet Resources
http://www.azdhs.gov/bhs/tr_resources/ea/pdf/pm.pdf
www.psychpage.com/learning/library/.../mse.htm
aitlvideo.uc.edu/aitl/MSE/MSEkm.swf
www.psychpage.com/learning/library/.../mse.htm

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