By Bivin Jose. II MSc in Psychiatric Nursing National Institute of Mental Health and Neurosciences, Bangalore

1. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
UNIT- 1 PSYCHIATRIC INTERVIEW
Dr. R. Parthasarathy Ms.Shobitha Dr.Nagarajaiah
Professor Ph.D Scholar & Psy.Social Worker Associate professor
Dept. of psychiatric social work Dept. of Nursing
NIMHANS, Bangalore-29 NIMHANS, Bangalore-29
Interviewing requires linguistically and culturally effective 7. Medical history: All medical disorders past and present
communication skills, interviewing, behavioral observation, and their treatments and childhood disorders that
data base record review and compressive assessment of the involve the central nervous system. For females,
client and relevant systems enables the psychiatric mental pregnancy status - especially if on psycho tropics or
nurse to make sound clinical judgments and plan appropriate expecting the use of psycho tropics and precautions
interventions with the client. against pregnancy and concomitant pharmacological
treatment can all patients, but particularity in consult-
Interviewing is a specific type of guided and limited
liason work, the medical history includes the
intercommunication with an identified purpose. An interview
interrelation of medical and psychiatric conditions.
is usually conducted to collect a database for analysis and
decision making purpose. 8. Social history, pre-morbid personality - early
developmental history: Early developmental history,
The goal of the initial diagnostic interview is to collect specific,
description of pre-morbid personality as baseline for
detailed information about 15 topics. These topics constitute
patient's best level of functioning. The patient's
the psychiatric evaluation.
psychosocial and environmental conditions
1. Identifying data: Patient's name, sex, age, marital status, predisposing to precipitating, perpetuating and
address, occupation, income, etc protecting against psychiatric disorders. Pre morbid
2. Chief complaints: The chief complaint in the patient's versus morbid functioning. Present support system.
own words. Alternatively signs of disordered functioning 9. Family history: Psychiatric history of first-degree
observed by the interviewer. relatives, including treatment response as possible
3. Informants: A list of all informants, their reliability, and genetic predisposition for the patient.
level of cooperation; also previous hospital records, if 10. Mental status examination: Appearance,
available. Such informants are essential in consciousness, psychomotor functions, speech,
circumstances that prevent the patient from providing thinking, affect, mood, suggestibility and thought
adequate information. Choosing the right set of content; cognitive functions such as orientation,
informants is more important than having a great memory, intelligence and executive functions; insight
number of informants. and judgement.
4. Reason for admission/consultation: the referral source; 11. Diagnostic formulation: Summary of biological,
in case of hospitalisation, statement of legal status - psychological and social factors contributing to patient's
voluntary - and the reason why hospitalisation is the psychiatric disorders.
safest and least restrictive environment for treatment.
12. Differential diagnosis: Discussion of diagnostic options
5. History of present illness: Early manifestations and based on overlapping symptomatology
recent exacerbations of all psychiatric disorders
13. Multiaxial classification: Information on all five axes
present; review of diagnosis and treatments given by
other providers. 14. Assets and strengths: Inventory of patient's knowledge,
interests, aptitudes, education, and employment status
6. Psychiatric disorders in remission: Psychiatric
to be used in the treatment plan.
disorders presently in remission; especially substance
abuse disorders; psychiatric disorders first diagnosed 15. Treatment plan and prognosis: Account of
in childhood and adolescence and their treatments. psychopharmacological, psychological and social
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2. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
treatment modalities planned, frequency of visits and 3. Guidelines for interviewing
list of providers; discharge criteria if inpatient. 1. Build rapport with the patient
For collecting such comprehensive information the interviewer 2. Conduct sessions seated in a private, comfortable area
has to master the styles of interviewing and apply them to the with adequate lighting and hearing distance
four components of the interview: rapport, techniques, mental
3. At the beginning of each session, plan and discuss
status and diagnosing.
with the client the length and purpose of the session.
2. Five phases of the psychiatric interview and four 4. Observe, listen and use facilitative communication
components techniques
The psychiatric interview progresses over time, which can be 5. Convey a professional demeanour through dress and
arbitrarily subdivided into five phases. These phases cover manner
the 15 topics of the psychiatric evaluation
6. Summarize the interaction at the end of the session
Phase I: Warm up and chief complaint (I to IV) and make arrangement with the client for the next
session
Phase II: The diagnostic decision loop (V)
7. Positively reinforce the client for his attention, effort and
Phase III: History and database (VI to X)
involvement
Phase IV: Diagnosing and Feedback (XI to XIV) 8. Maintain unity, progression and thematic continuity
Phase V: Treatment plan and Prognosis (XV) 9. Develop a good confidence so that the client is prepared
The five phases divide the psychiatric interview longitudinally. for self disclosure
Cross-sectionally, the interview consists of four components, 10. Maintain non-judgemental attitude and respond to self
which the interviewer must continuously monitor and propel disclosure with honesty, support and acceptance
throughout. 11. Limit your self-disclosure to a minimal level
1. RAPPORT: focuses on the therapist - patient
relationship; a good rapport is prerequisite for an effective
interviewer. Rapport is established in the opening; with a 4. Interview skills
cooperative and insightful patient, there is often little problem Careful listening
in establishing and maintaining a good rapport. However in
Attending
patient's who are uncooperative or show poor insight,
Demonstration of sincere interest
establishing a workable rapport with the patient becomes a
central issue. Expression of attentiveness through eye contact, body
language, verbal back and appropriate use of silence
2. TECHNIQUE: refers to the approaches the interviewer
uses to keep an interview 'on track'. It includes skills to Concreteness in questions/probing
appropriately select questions to arrive at a diagnosis. Good Immediacy - immediate importance
technique is necessary to therapeutically engage and work Experimental and didactic confrontation
with difficult patient's.
3. MENTAL STATUS: assessment captures the patient's
experiences, symptoms, signs behaviours, thought content, 5. Some do's and don'ts while conducting interview
cognitive level of functioning, insight and judgement during 1. Maintain eye to eye contact
actual time of the interview; however, in a patient with a 2. Interrupt only when necessary
significantly altered mental status - whether it be a boisterous,
3. Ask always open ended questions
irritable and uninterruptible manic patient, a minimally
responsive depressed patient or a paranoid patient - his or 4. Don't be in a hurry
her mental status plays a significant role in the interview. 5. Do not pass judgments
4. DIAGNOSIS: Pursues a progression in the diagnostic 6. Do not threaten
decision process from chief complaint to final diagnosis. 7. Don't belittle
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3. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
8. Be reassuring and supportive also assess the patient's non verbal cues in order to get an
9. Clarify accurate picture of the patients mental status.
10. Give time Reference:
11. Prepare 1. Booklet on clinical skills in psychiatric nursing.
12. Record the information after the interview is over Department of nursing. National Institute of Mental
Health and Neuro Sciences Bangalore-560 029.india/
Getting maximum information, in a short time as possible, 2009.
without causing any distress to the client is "good interviewing"
and it is an art. By practice one can master it. 2. Kathy Neeb. Fundamentals of mental health nursing.
3rd ed. Jaypee. New Delhi. 2008
3. Sreevani R. a guide to mental health and psychiatric
Conclusion: nursing. 3rd ed. Jaypee. New Delhi.2010.
Interview is a method by which the nurse starts establishing a 4. Vracarolis EM, Halter MJ. Foundations of psychiatric
therapeutic relationship with the patient. The nurses need to mental health nursing- A clinical approach. 6th ed.
use her verbal and non verbal communication techniques and Saunders. St. Louis . 2010.
3

4. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
UNIT-2 PSYCHIATRIC HISTORY-TAKING
Dr.Nagarajaiah
Associate professor
Dept. of Nursing
NIMHANS, Bangalore-29
A comprehensive, accurate and adequate history from the 11. Income (annual) : Self - Family -
patient and reliable informant will help in understanding the
12. Religion : Hindu / Muslim /Christian / others
problems of the patient and also in planning the appropriate
management. With regards to psychiatric patients it is very 13. Reasons for consultation/admission:
important to obtain information from a close relative or a person 14. Source of referral and reasons for referral:
who knows well about the patient. This is because psychiatric
patients are not aware of the extent of their symptoms always. Source of Information gathered from: adequate/ reliable
For example a schizophrenic patient may not realize how much
embarrassment he has caused by his disturbed behavior and 2. PRESENTING COMPLAINTS (chronological):
also in case of alcoholics, they may know their problems but The duration of each presenting complaints should be
may not wish to reveal them. mentioned in chronological order
History should always be recorded systematically and in the
same order to ensure that the interviewer does not forget
important themes or events. Given below a standard scheme 3. HISTORY OF PRESENT ILLNESS:
of history taking in the form of list of topics to be covered. The Duration
trainee must learn by experience how to adjust his questioning
Current episode /exacerbation:
to problems that emerge as the interview proceeds. This is
done by keeping in mind the decisions about diagnosis and Mode of onset : Abrupt <48 hrs Acute <1wk Insidious 1-2
management that will have to be made at the end of the Sub acute few weeks - months
interview.
Course : Continuous /Episodic /Unclear (Fluctuating /
1. SOCIO DEMOGRAPHIC DATA Deteriorating /Improving)
1. Name : Precipitating factors : (Describe) this can be physical (e.g
febrile illness) or psychological in nature (death/loss).
2. Father's / spouse name:
Description :
3. Address :
Chronological account, describe major abnormal behavior,
4. Phone number :
associated problems like homicide/ suicide/ disruptive
5. Age : behavior/ thought content as expressed in speech/ writing,
6. Sex : major mood states, abnormal perceptions and experiences,
biological functioning, occupational functioning, effects on
7. Languages known : work, social functioning, changes in daily life etc. Description
Can speak Can write Can read of the time relations between symptoms and social
psychological and physical disorder needs to be mentioned.
Mother tongue :
Associated disturbances in sleep, appetite, and sexual drive
Other languages : have to be mentioned. Any treatment received, improvement
and deterioration has to be noted down.
8. Marital status :
Scheme for substance abuse/ dependence cases:
single /married /separated /divorced / widow /widower /other
Mode of initiation, duration, quantity of consumption, early
9. Education :
pattern of intake, progression, salience, tolerance, craving,
10. Occupation : physical withdrawal features, pattern of use in recent and past,
medical complications (including accidents) neuropsychiatric
4

5. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
problems, interpersonal problems, socioeconomic problems
(including debts if any) occupational problems, problems with
law, earlier attempts to abstain, reason for consultation,
motivation for abstinence etc.
In cases of multi substance use describe separately for each
substance.
Treatment history
Note the details regarding treatment received. For e.g.:
Magic-religious/ other systems like Homeopathy/ Ayurveda/
Allopathic
Psychiatric pharmacotherapy- name of the drug; duration; D
D
dosage; side effects; compliance; others.
ECTs- No. of ECT's. Reason
Psychotherapy
D
Family interventions
Rehabilitative measures
Negative history
Major features that are usually present in the given
syndrome
History of trauma, fever, headache, vomiting, confusion,
memory disturbances,
Physical illnesses like, hypertension, diabetes, etc.
Other major psychiatric illnesses
Organic causes
Substance abuse
4. PAST HISTORY:
Chronological account since childhood has to be noted down.
If possible draw an life chart. Describe each episode briefly
with onset, events, major features, course and duration,
treatment taken, level of recovery.
Psychiatric illness: ^
Medical illness:
5. FAMILY HISTORY:
Describe each family member briefly: age, death, mode of
Genogram - Family of origin death, education, occupation, health status - physical and
psychological illnesses, major personality traits, relationship
Draw the tree for three generations on both sides in cases of
with client, include other significant members.
genetic importance
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6. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
Details of family functioning 9. Social support system:
1. Type of family : (Nuclear / Joint / Others) 10. Other :
2. SES : (Upper / Middle / Lower)
3. Leadership pattern: History of illness in family:
4. Role functions : Psychiatric: similar illness, other illness, other major
behavioural problems like delinquency, personality problems,
5. Communication with in the family and others:
suicide, substance use, epilepsy, mental retardation.
6. Child rearing practices:
Medical: (Especially hereditary)
7. Interpersonal relationships:
8. Social position :
6. PERSONAL HISTORY:
Birth and development :
Antenatal period : Uneventful / Eventful (specify)
Birth history : Full term /Premature / Post mature, Normal /Forceps/ Caesarean/ Delayed birth cry / any other
complications.
Post natal history : Uneventful / Eventful (specify)
Physical health during infancy: Good / poor (specify)
Immunization schedule : Completed / not completed
Developmental milestones : Normal / Delayed
Motor :
Adoptive :
Speech :
Social :
Childhood health : Normal/ Abnormal/ Trauma/ Fever/ Convulsions/ Any other illness
Behavioral and emotional
problems : (Nail biting, thumb sucking, sleep disturbances, tics, mannerisms, Enuresis, Sleep walking,
Temper tantrums, stammering. Look for conduct disturbances like frequent fights, truancy,
stealing, gang activities and relationship with parents, siblings and peers)
Home atmosphere during
childhood : Satisfactory / Unsatisfactory
Emotional problems in
adolescence : running away / delinquency/ smoking/ drug taking/ over weight/ identity problems
Home atmosphere during
adolescence : Satisfactory / Unsatisfactory
Parental lack : Yes / No (Dead/ separated fro more than one year/ habitually absent from home)
Anomalous family situation : Yes / No (Step parent, adoption status)
Comments :
Educational history :
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7. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
Age of beginning :
Age of finishing :
Relationship with teachers :
Relationship with schoolmates
(include nick names, bully or
butt of jokes :
Position in class : (Top / Middle / Low)
Special abilities :
Active participation in games:
Other extracurricular activities :
Occupational history :
Work record : Satisfactory / Unsatisfactory
Frequent changes of jobs : Yes / No
Work position : Raising / Falling / Stationary
Age at the time of starting to
work :
Jobs held in the past (in chronological order, with wages, dates, reasons for change)
Present job : Duration:
Satisfied with work : Yes / No (Reasons for dissatisfaction)
Sexual history:
Information about sex : (How acquired, of what kind, how received, adequacy of knowledge, attitude towards opposite
sex)
Masturbation : Age of starting : Frequency: (Guilt/ attitude if any,)
Sexual experience : (Homo/ Hetero/ Pre and extra marital / preferences)
Any complaints including
Dhat syndrome :
Menstrual history :
(Age at menarche / how regarded / regularity / duration / cycle / amount / physical / emotional problems)
Menopause : (Age / climacteric symptoms)
Marital history:
Genogram - family of procreation
Date / year of marriage (Arranged / affair)
Spouse : (Age, education, occupation, personality)
Marital relationship : Satisfactory / Unsatisfactory
Sexual relationship : Satisfactory / Unsatisfactory
Contraceptive practices :
Children: (Chronological list of children, miscarriage and still births (age, education, occupation, personality for each child,
relationship with client)
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8. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
7. PREMORBID PERSONALITY: Conclusion:
(Give details and cite examples from patients past life) History taking is the first for managing a patient in the psychiatric
i. Social relations set up. A well taken history in itself is enough to diagnose as
ii. Intellectual activities : Hobbies and interests well as management the patient. Therefore the art of taking
history should be essentially inculcated in all psychiatric
iii. Mood (cheerful, strung up, optimistic, pessimistic, stable,
nurses.
fluctuating etc.)
iv. Character Reference:
a. Attitude to work and responsibility 1. Booklet on clinical skills in psychiatric nursing.
b. Interpersonal relationships Department of nursing. National Institute of Mental
Health and Neuro Sciences Bangalore-560 029. India/
c. Standards in moral, religious, social and health matters.
2009.
d. Energy and initiative
2. Kathy Neeb. Fundamentals of mental health nursing.
v. Fantasy life
3rd ed. Jaypee. New Delhi. 2008
8. Habits:
3. Sreevani R. a guide to mental health and psychiatric
Eating fads / patterns nursing. 3rd ed. Jaypee. New Delhi.2010.
Sleeping patterns
4. Vracarolis EM, Halter MJ. Foundations of psychiatric
Excretory functions mental health nursing- A clinical approach. 6th ed.
Alcohol consumption Saunders. St. Louis . 2010.
Tobacco consumption
Self-medication with drugs
8

9. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
UNIT-3 SYMPTOMATOLOGY IN MENTAL DISORDERS
Dr. Ramachandra
Associate professor
Dept of nursing, NIMHANS, Bangalore-29
The systematic study of cognition and behavior is called b) Stereotype Movement
'psychopathology'. Symptoms are the result of many forces.
Their origin is usually within the patient. The symptoms may Mannerisms: These are stereotyped movements
be very bizarre but have a cause and meaning. Various commonly seen in Schizophrenia. Ex: grimaces
symptoms observed in mental illness are addressed under repeated gestures and peculiarities of gait etc.
the following headings. c) Stereotype Speech
1. Disorders of motor aspects of behavior Verbigeration: Repetation of words phrase or sentence
2. Disorders of perception is called verbigeration.
3. Disorders of thinking 1.5 Automatic Behaviour
4. Disturbances of affect In this patient follows compulsively and automatically
suggestions and requests. This is seen in two forms:
5. Disturbances of attention
Echolalia: patient repeats the words or phrases which
6. Disorders of consciousness are spoken in his presence.
7. Disorders of orientation Echopraxia: patient imitates the action of others.
8. Disorders of memory 1.6. Negativism
It is a psychological defense reaction manifested by
1. DISORDERS OF MOTOR ASPECTS OF BEHAVIOR opposition and resistance to what is suggested. This
Motor disturbance are related to action or impulse toward can be exhibited in different forms such as mutism,
action. It is called conation. These activities are related refusal of food and noncompliance with requests etc.
to attitude and feeling. Negativism provides gratification by the acting out of
hostile, revengeful feelings towards significant persons.
1.1. Increased activity (over activity)
Increased activity may be goal directed. But sometimes 1.7. Compulsions
the goal of the activity is constantly changing so no A morbid and often an irresistible urge to perform
objective is achieved. Ex: Mania. Even the stream of the purposeless act repetiously is known as compulsion.
thought is characterized by flight of ideas. Ex: touching an object twice or may take form of ritual.
1.2. Decreased activity
1.8. Violence
Patient takes long time to start the activity when it gets
started they do it very slowly. They have to make lots of Violence is an expression of aggressiveness in the form
effort to do it. In extreme form, the patients are mute and of murders, assaults, rape damaging self and others
motion less. Ex: severe depression. and suicide.
1.3 Repetitious activities 1.9. Suicide
The patient repeats the activity in the same manner for It means self-destruction. People with suicidal ideation
an indefinite period. have sense of lack of love and affection and deep sense
1.4 Stereotypy of personal rejection. They also suffer from self-
derogatory attitude, profound feelings of hopelessness
Persistent and constant repetition of certain activities
and helplessness. The suicidal attempt is motivated by
and may be of position, movement of body or speech.
the wish for revenge or by wish-fulfilling fantasies of
Stereotypy is seen in the following forms.
reunion in death.
a) Stereotypy position
Catalepsy: A constantly maintained immobility of position
is known as catalepsy. It is frequently seen in DISORDERS OF PERCEPTION
Schizophrenia. Disorders of perceptions are classified as illusions and
Waxy -flexibility: Here patient flex his extremities like wax hallucinations.
in awkward position and remains in that position for
long time.
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10. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
Illusions B. Retardation: In this initiation and thought are slow;
patient will speak slowly and usually in low tone.
Illusions are mistaken or misinterpretations of sense
Patient will complain that he has difficulty in thinking.
impressions. Ex: patient perceives rope as a snake. Illusions
It usually occurs in depressive phase of affective
occur due to individual emotional state, needs and fears.
psychoses and may be in schizophrenia.
Hallucinations
C. Perseveration: In this abnormal, persistent repetition
Hallucination is a perception without object. Hallucinations or continuance is seen in expression of an idea. It
should be looked upon as mental products which, arising occurs in aphasia, catatonia and in senile dementia.
from within and not related to any external stimulus. They
D. Circumstantiality: This is also disturbance of flow of
represent a breakthrough of preconscious or
thought in which patient includes many unnecessary
unconsciousness in the form of sensory images in response
details before the goal is finally reached. This is seen
to psychological situations and needs.
in feeble-minded, epileptics and in advanced senile
Types of Hallucinations mental disorders.
1. Auditory Hallucinations: These are most common form E. Incoherence: This is characterized by confusion due
of perceptual disturbances. These are sometimes in the to repressed material highly charged affectively. In
form of noises but commonly in clear words or complete this one idea runs in to another with logical sequence.
sentences addressed to him. It occurs in schizophrenia.
2. Visual Hallucinations: These are not common as auditory F. Tangentiality: In this disorder of progression of thought
hallucinations. These occur most commonly in delirium patient begins to respond, follows a series of related
tremens in which patient sees terrifying images and topics but never reaches the goal finally. It is common
causes fear to the patient. in Schizophrenics.
3. Olfactory Hallucinations: These are hallucination of smell, G. Blocking: When patient is talking and suddenly he
commonly seen in Schizophrenic states and with lesions stops talking. It means sudden interruption in train of
of the temporal lobe. They are unpleasant and represent thought. It occurs when one feels strong affect. Eg
feelings of guilt. anger or terror and Schizophrenics.
4. Gustatory Hallucinations: these are hallucinations of taste. 3. Disorders of content of thought
They rarely occur alone but are associated with olfactory
A. Overvalued or over determined ideas: When an idea
hallucinations.
has strongest feeling tones it tends to dominate and
5. Tactile Hallucinations: these are the hallucinations of the we call it over valued idea. Overvalued idea becomes
touch. They occur principally in toxic states. Ex: delirium most important determinant of behavior. This is how
tremens, in cocaine addiction and in Scxhizophrenia also. delusion occurs.
6. Kinesthetic Hallucinations: The phantom phenomenon. B. Delusions: The delusion is defined as common false
Ex: to feel pain in the amputated part of limb. This is the beliefs, which are irrational, not shared by persons of
most common form of kinesthetic hallucinatory experience. same race, age and standard of education, which is
held by conviction and which cannot be altered by
DISORDERS OF THINKING
logical arguments and which are persistent.
Thought is the most highly organized psychobiological
Types of Delusions
integration and a form of implicit or internal behavior.
I. Delusions of grandeur: Delusional beliefs of great
1. Disorders in the form of thought
power, wealth and influence. Ex: he may say he is
Thinking is the product of stimulus and response. Stimuli for god. This delusion arises from feelings of insecurity
thought come from various sources. In day dreaming thinking or inferiority.
is directed by egocentric wishes and instinctual needs. In case
II. Delusions of Self-accusation: it arises when super-
of Schizophrenia, thinking is directed by unconscious factors.
ego becomes critical became repression gets
Ex: autistic thinking or drastic thinking.
weakened and patient has vague feeling of guilt. This
2. Disorders of progression of thought (Stream of thought) sense of guilt takes the form of self-accusation.
The following are the disorders of the thought. III. Delusions of persecution: Delusional beliefs of an
individual that he is being deliberately interfered with,
A. Flight of ideas: This is the disturbance of the stream discriminated against, threatened or otherwise
of thought in which thinking process appear to run mistreated. He feels others are planning to harm him.
too quickly yet no idea is completed is known as flight These delusions permit a shifting of responsibility
of ideas. This happens because of increased inner and otherwise serve to relieve anxiety arising from
drive and distractibility. Sometimes a word similar in guilt. It occurs in chronic psychotic disorders.
sound but not in meaning calls up the new thought
and may lead to senseless rhyme, e.g. Sit, sob, sigh, IV. Ideas of reference: Delusional beliefs that other
sorrow. This is called clang- association. people are talking about him referring to him or that
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11. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
the remarks or actions of people he meets are 3. Anxiety
intended to have some special significance for him.
It is a persistent feeling of dread, apprehension and
In paranoid states ideas of reference represent a
impending disaster. The patient is ignorant of its source.
projection of the patients own self-criticism on to the
Following are the different states of anxiety.
world. In depression, feeling of guilt may stimulate
ideas of reference. A. Free-Floating anxiety: It means anxiety is not attached
to any ideational content but is felt as a morbid fear
V. Delusion of guilt : Impoverishment and illness These
without apparent source.
occur mostly in depressive cases. In this
unconscious hostile tendency may be projected B. Agitation: when anxiety is severe and over flows in
outward giving rise to fear of punishment. this way in to the muscular system, producing gross
motor restlessness, the reaction of the patient is
C. Hypochondria: In this patient shows exaggerated concern
called agitation.
over physical health. In this anxiety is displaced from
unconscious mental sources to organs. It occurs in people C. Tension: In this patient feel restlessness,
who have shown previous tendency to evade the dissatisfaction, dread and discomfort. Tension is
responsibilities of life through illness. accompanied by neuromuscular setting.
D. Obsessions: Thoughts that persistently push themselves D. Panic: It is a pronounced state of anxiety which
in to consciousness against the desire of the patient are produces disorganization of ego functions. It occurs
known as obsessions. Obsession thoughts are strongly in some long standing insecurity of the personality
charged with the emotions of guilt or depression. Ex: which creates tension in threatening form the patient
patient keeps on asking why he was born. Obsession may show aggressiveness and about, pupils get
thoughts are closely related to compulsive acts. dilated and has difficulty in thinking, appearance of
bewilderment. Suicide may occur.
E. Phobias: Allied to obsessive thoughts the patient has fears
of dirt, bacteria,cancer or of crowds. 4. In adequate Affect
DISTURBANCES OF AFFECT This is emotional dulling or detachment in the form of
indifference, also called apathy. Patient does not feel pleasure
Affect is related to feeling which currently the person is having
or pain or any other sentiments. This absence of emotional
whereas mood is sustained feeling state of considerable
responsiveness may cause out of touch with reality. It may
duration. Affect serves as warning signal to refrain from a
appear as a protective, defensive reaction against painful
forbidden act. Affect influence our thoughts and ideas.
perceptions.
1. Pleasurable affects
5. Inappropriateness of affect
A. Euphoria: It is the feeling of emotional and physical
wellbeing. In this patient has optimistic mental 'set' and It is a disharmony of affect. It is common emotional
is confident and assured in attitude. It is present in disturbance, seen in Schizophrenia.
hypomanic states and in certain organic state. Ex: 6. Ambivalence
general paresis, multiple sclerosis and in frontal lobe
tumor. It means existence of contradictory feeling, attitudes toward
the same object or person. Both of these conflicting attitudes
B. Elation: patient feels overjoyed. Self-confidence
are faces of the same coin, while only one may be visible, the
radiates from him. Elation is often labile and readily
other is nevertheless present. Ex: feeling of love and hate
shifts to irritability. It is accompanied with increased
towards the parents.
activity.
C. Exhalation: there is an intense elation accompanied by 7. Depersonalization
an attitude of grandeur. It is an affective disorder in which feelings of unreality and a
D. Ecstasy: It's a feeling of extreme joy and tranquil sense loss of one's own identity are experienced. The unreality
of power. It can occurs in dissociative epileptic, symptoms are of two kinds; a) feeling of changed personality
Schizophrenic and affective reactions. b) a feeling that the outside world is unreal. Patient feels that
he is no longer himself but he does not feel that he has become
2. Depression
someone else.it occurs in hypochondria, obsessional states
It is an effective feeling tone of sadness. It is the commonest and hysteria
type of complaint in psychiatric patient. It can vary from milder
DISTURBANCES OF ATTENTION
depressive syndrome to deeper depression. In milder
depressive syndrome the patient is quiet, restrained, inhibited, Organism examines the external world for useful data is known
unhappy, pessimistic has feeling of inadequacy and as attention.
hopelessness and the same feelings are in extreme form in
deeper depression. 1. Disordered attention
Grief: it is an effect of sadness due to loss of a close relation, Fatigue toxic states and organic lesions interfere and lower
may be death of a person. attention.
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12. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
2. Distractibility a) Registration: it means reception of the mental
impression
The inability to hold attention for a sufficient length of time
is called distractibility. In Schizophrenia the degree of b) Retention: it means preservation of the previous by
attention is greatly diminished. acquired impression.
DISORDERS OF CONSCIOUSNESS c) Recall: It means reproduction of the impression.
Impairments in consciousness from least to the greatest are The following are the disorders of memory are
states of confusion, clouding of consciousness, delirium,
1. Hypermnesia: It's an exaggerated degree of retention
dream and fugue states to complete stupor.
and recall. It occurs in mild manic states, paranoia and
1. Confusion: It is a disturbance of consciousness catatonia impressions with which strong emotions are
characterized by bewilderment, perplexity, disorientation, attached.
disturbance of associative functions and poverty of ideas.
2. Amnesia: It means loss of memory or inability to recall
It occurs in diffuse impairment of brain tissue functions
past experience. It can occur in physiological
associated with toxic, infections or traumatic agents.
disturbances of neurons through chemical alterations
2. Clouding of consciousness: It is a disturbance in which or trauma. In psychogenic amnesia, recall is not present
clear mindedness is not complete because of physical or for psychogenic reasons.
chemical disturbances producing functional impairment
The types of amnesia are
of the associative apparatus of cerebrum.
A. Anterograde amnesia: confined to recent events and is
3. Delirium: It is also designated as the acute brain
progressive.
syndrome. It consists of much more than clouding of
consciousness. Delirious reactions occur in infective B. Retrograde amnesia: involves the past events and is not
states, puerperial psychoses. progressive.
4. Dream state: This is also called twilight state. There is 3. Paramnesia: It is a falsification of memory as well as
consciousness disturbance and patient is not aware of distortions of memory also serves as protection against
his surroundings. intolerable anxiety. There are various types as follows:
5. Stupor: In this patient is motionless and mute but with A. Confabulation: the patient fills the gaps in his memory
relative preservations of conscious. Movement of eyes and by fabrications which are without any basis of fact. This is
respiration occur. It can occur in toxic-organic brain seen in senile psychoses and particularly in Korsakoff's
disease, intense apathy, profound depression blocking, syndrome.
epilepsy and dissociative reaction to overpowering fear.
B. Retrospect falsifications: These are illusions of memory,
DISORDERS OF ORIENTATION created in response to affective needs. It means
unconsciously selecting the memories which suit our
The process by which one understands his surroundings and
interests.
locates himself in relation to it is known as orientation. If a
person knows his position in reference to time, place and 4. Déjà vu: This is an experience of seeing with the feeling
person, he is said to be oriented. Disorientation may occur in that one has seen it before but does not know when and
organic brain syndromes and in acute conflicts. where. This is seen in Schizophrenia, Psychoneuroses,
lesions of the temporal lobe including epilepsy and states
DISORDERS OF MEMORY
of fatigue or intoxication.
The function by which information is acquired and presented
Conclusion:
to consciousness and attention is stored, later same is
recalled to consciousness is known as memory. It has three Psychiatric symptoms are difficult to identify yet once identified
processes. it forms as the basis of the patient's treatment. Therefore, it is
crucial on the part of the nurse to know about it.
Reference :
1. Gail W. Stuvart and Michele T. Laria. Principles and
Practice of Psychiatric Nursing, 8th Edn. Elfvier New
Delhi, 2005, 35-38.
2. Lalitha K. Mental Health and Psychiatric Nursing -
An Indian Perspective, 1st Edn. VMG Book House,
147-149.
12

13. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
UNIT-4 MENTAL STATUS EXAMINATION
Dr. Sailaxmi Gandhi
Assistant Professor,
Department of Nursing, NIMHANS, Bangalore - 29
The mental status examination (MSE) is a standardized rapport can be established and does the client maintain
procedure where the primary purpose is to gather more adequate eye contact.
objective data to be used in determining etiology, diagnosis,
1.3 Overt behaviour and Psychomotor activity (PMA):
prognosis, and treatment, and to deal immediately with any
Psychomotor activity (PMA) can be simply termed as goal
risk of violence or harm (Kneisl, Wilson Trigoboff, 2004).
directed activity. PMA can be increased, decreased or normal.
Definition: The MSE is the part of the clinical assessment that There can be psychomotor retardation; aimless, purposeless
describes the sum total of the examiner's observations and activity; restlessness, wringing of hands, pacing; gestures,
impressions of the psychiatric patient at the time of the interview twitches, stereotyped behaviour (repetitive, fixed pattern of
(Kaplan Sadock, 1998). physical action). Catatonic phenomena such as excitement,
stupor, rigidity, posturing, mutism, etc. should be noted and
Uses: The MSE is very useful to the psychiatric nurse. Some
recorded.
of these uses are:
2.SPEECH:
1) It helps formulate the nursing diagnosis after identifying
the clients problems Speech can be described in terms of quantity, rate of production
and quality. One has to note whether the client speaks
2) It helps the nurse teacher to teach nursing students
spontaneously, amount of speech, tone, tempo, reaction time,
about the psychiatric client's symptoms of illness
prosody and whether the speech is relevant and coherent.
3) It can be used to test effectiveness of various nursing
3. THOUGHT:
interventions on the psychiatric client.
Thought can be assessed under the following components
4) It helps to assess changes in the psychiatric client
such as -
during various stages of nursing interventions
3.1 Form: This is the way a person puts together ideas and
5) It helps the nurse to assess when the client is fit for
associations, i.e. the form in which a person thinks. There
discharge and to prepare the client for community life
may be rapid thinking, which, when carried to the extreme, is
A The format for writing up the MSE may vary slightly depending called as flight of ideas. There may be incoherent
on the organization. However, the format must contain certain connections of thoughts (word salad), association by rhyming
categories of information, which is included as follows: (clang associations), etc.
1 GENERAL BEHAVIOR: 3.2 Stream: This is best described as flow of thought, train of
1.1 Appearance: This is a complete and accurate description thought or continuity of thought. E.g. Loosening of association,
of the client's physical characteristics, apparent age, manner blocking, circumstantiality, tangentiality, perseveration, etc.
of dress, use of cosmetics, personal hygiene, and responses 3.2 Possessions: These could be thought alienation - thought
to the examiner. One has to include posture, gait, gestures, insertion (the client describes insertion of strange thoughts
facial expression, tics, mannerisms, poise, etc. (A tic is an which do not belong to him), thought withdrawal (the client
involuntary, spasmodic motor movement. A mannerism is an describes a feeling of emptiness in the head as he feels
ingrained, habitual, involuntary movement.). Signs of anxiety thoughts being removed), and thought broadcast (client
to be noted are tense posture, increased sweating, wide eyes, describes a strange situation where all his thoughts are
moist hands, etc. broadcast in the TV, radio, etc.). Obsessions may be elicited
1.2 Attitude towards examiner: The client's attitude towards which are pathological persistence of an irresistible thought
the examiner may be described as co-operative, friendly, or feeling that cannot be eliminated from consciousness by
attentive, interested, seductive, defensive, perplexed, apathetic, logical effort. When these are present, clarify the nature of
hostile, playful, ingratiating, evasive or guarded. Check if compulsive acts - checking, counting or washing and whether
13

14. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
they are controlling or yielding. Phobias may also be present. Assessment is done by asking the following questions:
These are persistent, irrational, and usually pathological dread
a) Have you ever heard voices when no one was around
of a specific stimulus resulting in a compelling desire to avoid
or sounds that no one else could hear?
the stimulus.
b) Have you experienced any strange sensations in your
3.3 Content: Disturbances here include preoccupations
body that others do not seem to experience?
(which may involve the client's illness), antisocial urges,
hypochondriacal and somatic symptoms, and depressive c) Have you seen things that others do not seem to see?
ideation (ideas of worthlessness, guilt, hopelessness and 5.2 Types of Hallucinations: Command hallucinations: False
suicidal ideas and delusions. Delusions are firm, fixed and perception of orders that a client may feel obliged to obey, First
false beliefs out of keeping with the client's cultural background. person hallucination: False perception of hearing an echo of
Some common delusions are delusion of poverty i.e.a person's one's own thoughts, Second person hallucinations: False
false belief that he or she will be deprived of all wealth, delusion perception of hearing two voices talking to the client, Third
of persecution i.e. a false belief that he or she is being harmed person hallucinations: False perception of hearing many
or persecuted, delusion of grandeur i.e. a person's voices discussing about the client or in the form of a running
exaggerated conception of his or her importance, power or commentary, De- personalization: A person's subjective sense
identity, etc. of being unreal, strange or unfamiliar, De-realization: A
4. MOOD: subjective sense that the environment is strange or unreal.
Mood is defined as a pervasive and sustained emotion that
colours the person's perception of the world (Kaplan Sadock, 6. COGNITIVE FUNCTIONS:
1998). Mood should be assessed by both subjective report
and objective evaluation. Various components should be Here clinical assessment includes the areas of -
described such as quality of emotion e.g. Happiness, 6.1 Orientation
sadness, anxiety, anger, fear, etc., range of mood which can
6.2 Attention Concentration
be broad where the person is able to experience all mood
states or blunted, constricted and flat (with gradual decrease 6.3 Memory
in emotional expression with absolutely no expression in flat
6.4 Intelligence
affect), lability of mood i.e. rapid and sudden shifts in emotion
from one emotional state to the other, reactivity i.e. changes in 6.5 Abstraction
emotion in relation to environmental factors, congruity i.e. 6.6 Judgement
emotional expression in relation to thought processes (e.g.
Smiles while talking about success in exams) and 6.7 Insight
appropriateness i.e. emotional expression in relation to
situations (E.g. Laughing during a funeral is inappropriate
6.1 Orientation: Orientation is tested with respect to time,
while crying during a funeral is appropriate).
place and person
5. PERCEPTION:
6.2 Attention Concentration: One has to test whether
The client may experience perceptual disturbances, such as attention can be aroused and sustained.
hallucinations, illusions, depersonalization and derealization.
Hallucinations are false sensory perceptions occurring in the
absence of a real stimulus. One should always specify the Tests used in the clinical situation include:
sensory modality involved (auditory, visual, olfactory, tactile,
6.2.1 The digit span test
gustatory) when hallucinations are experienced and also
describe the content of the hallucinations. With respect to 6.2.2. Serial subtraction
auditory hallucinations, always enquire whether the
6.2.3 Days or months forward to backward
hallucinations are verbal/non-verbal, continuous/intermittent,
single voice/multiple voices, familiar/unfamiliar, pleasant/ 6.2.1 Digit span test:
unpleasant, whether commanding, abusive or threatening, a) Forward: The client is given the following instructions: I
mood congruent/mood incongruent and first person/second will be saying some digits, listen to me carefully. When I finish
person or third person. saying them, you will have to repeat them in the same order.
14

15. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
The examiner after instructing the clients, gives an example Inference is noted as comprehension is good or bad.
for digit forward (e.g. If I say 3,7; you say 3,7) and for digit
6.4.3 Arithmetic: Tested by asking the client to solve simple
backward ( e.g. if I say 2, 5; you should say 5, 2) The digits
to complex problems in addition, subtraction, division and
forward/backward score is the highest number of digits
multiplication. Illiterate clients can be asked questions such
correctly recalled forward/backward after a maximum of two
as - How many tsp. of sugar and tea leaves are required to
trials.
make tea for 5 persons?
6.2.2 Serial Subtractions: Increasingly difficult tests are
Inference is recorded as - arithmetic is good, average or bad.
presented. The examiner
6.5 Abstraction: Abstract thinking is the ability to deal with
1. Instructs the client
concepts.
2. Gives an example of how to perform the task
6.5.1 Can the client explain similarities between a dog and a
3. Notes the responses verbatim lion?
4. Notes the time taken in seconds 6.5.2 Can the client state the difference between cinema and
radio?
Task Correct response Time limit
6.5.3 The client is asked if he knows what a proverb is and to
20-1 20 to 0 15 secs
state one with the meaning. Then the examiner states a
40-3 40,37,31, etc 60 secs. proverb and asks for the meaning.
100-7 100,93,86,79, etc. 120 secs. The client's response is to be noted verbatim. Inference is
made as abstraction present at concrete level (when specific
explanation is given) or concrete and abstract level (when both
6.2.3 Days or months may be asked for in backward or forward
specific and abstract explanations are given).
order.
6.6 Judgement: Is assessed in the following areas
The inference is recorded as attention can be aroused and
sustained. Concentration is good, average or poor 6.6.1 Personal: Enquire about the clients future plans
6.3 Memory: Memory functions are divided into immediate,
6.6.2 Social: Observe the clients behaviour in social situations
recent and remote. Memory impairment can occur in different
or ask how he would dress up for a funeral/wedding?
types of schizophrenia, psychosis, depression, dementia, etc.
Assessment includes immediate, recent and remote memory 6.6.3 Test: Present the following two problems to the client in
a manner in which he can comprehend:
6.3.1 Immediate memory - Tested by the digit span test
6.3.2 Recent memory - Is tested by enquiring about what the a) Fire problem: What will you do if your house catches fire?
client had for breakfast, events of the day and what he ate the b) Letter problem: What will you do if you see an addressed,
previous night, etc. sealed and stamped envelope which someone had dropped
6.3.3 Remote memory - Test by asking for information on life when you are walking on the roadside?
events
Inference may be - Personal/Social/Test judgement is intact
Inference may be noted as follows - eg. Recent memory is or impaired.
intact or impaired
6.7 Insight: Insight is the client's degree of awareness and
6.4 Intelligence:
understanding about being ill.
6.4.1 General information: Question the client according to
the educational level and background of the client. Common The level of insight with the inference is as given below:
questions can be- Name of the Prime Minister, major cities of a) Complete denial of illness (Insight is absent)
India, etc.
b) Recognizes the presence of illness but gives explanation
Inference may be noted as follows - General information is
in physical terms i.e. headache, fever, etc. (Insight is partial)
adequate or inadequate or average
6.4.2 Comprehension: Ask questions of increasing difficulty c) Fully realizes the emotional nature of his/her illness, cause
ranging from Eg. What will you do when you feel cold? -------- of the symptoms and feels he/she requires treatment (Insight
is present)
------ to--- Why should we be away from bad company?
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16. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
B. MINI MENTAL STATUS EXAMINATION (MMSE) 5.4 Read and perform the command Close your eyes
(1)
MMSE is a bed-side screening test which is not time
consuming and is a formal evaluation of cognitive impairment 5.5 Write any sentence (check subject, verb, object)
in the client. It is also a practical clinical examination to track (1)
the changes in the client's cognitive state. It is used as a
6. Construction Total score = 1
clinical test in mental disorders occurring due to a general
medical condition, such as delirium, dementia, amnestic 6.1 Copy the design below
disorders, etc.
The MMSE Questionnaire (Folstein M.F., Folstein S, McHugh Total MMSE score = 30
P.R.; 1975) is as follows:
Inference of score:
1. Orientation (Score 1 if correct) Total score = 10
1.1 Name this hospital or building
1.2 What city are you in now? 25 - 30 = Suggests no impairment
1.3 What year are you in now? 20 - 25 = Suggests impairment
1.4 What month is it? 20 = Indicates definite impairment
1.5 What is the date today?
1.6 What state are you in?
C EXAMINATION OF NON-COOPERATIVE OR STUPOROUS
1.7 What country is this? CLIENTS (Kirby, 1921):
1.8 What floor of the building are you on? It may be difficult to get information from non-cooperative or
1.9 What day of the week is it? stuporous clients. However, this can lead to delay in assessing
the client's problems, formulating nursing diagnosis and
1.10 What season of the year is it?
planning nursing care. Hence, to avoid this, this format can
be followed to assess the mental state of such clients.
2. Registration (Score 1 for each object correctly repeated) 1. General reaction and posture:
Total score = 3
1.1 Attitude is voluntary or passive
2.1 Name 3 objects and have the client repeat them Score the
1.2 Voluntary posture is comfortable, natural, constrained
number repeated by the client. Name the three objects several
or awkward
more times if needed for the client to repeat correctly (record
the number of trials----) 1.3 What does the client do if placed in awkward or
uncomfortable positions?
1.4 Behaviour toward physicians and nurses is resistive,
3 Attention Calculation Total score = 5
evasive, irritable, apathetic or compliant
3.1 Subtract 7 from 100 in serial fashion to 65. Maximum
score = 5 1.5 Spontaneous acts: any occasional show of playfulness,
mischievousness or assaultiveness. Defence
movements when interfered with or when pricked with
4.Recall Total score = 3 pin. Eats and dresses self. Pays attention to bowel
and bladder.
4.1 Do you recall the 3 objects named before?
1.6 To what extent does the attitude change?
(Score 1 for each object named correctly)
5. Language tests (Total score = 8) II Facial Expression:
5.1 Confrontation naming = watch, pen (2) Alert, attentive, placid, sulky, scowling, perplexed, distressed,
5.2 Repetition = No ifs, ands, or buts (1) etc.
5.3 Comprehension = Pick up the paper in your right hand, Any change of facial expression or signs of emotion - tears,
fold it into half, and set it on the floor (3) smiles, flushing, perspiration? On what occasion does this
change occur?
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17. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
III Eyes: VII Speech:
Open or closed. If closed, does he resist having the lid raised? Any apparent effort to talk, lip-movements, whispers,
Movement of eyes absent or can be obtained on request? movements of head?
Rolling of eyeballs upward. Blinking, flickering, or tremors of Note exact utterances with accompanying emotional
lids. reaction (may indicate hallucinations)
Reaction to sudden approach to threat to stick pin in eye.
Sensory of pupils (reacts equally) VIII Writing:
IV Reaction to what is said or done: Offer paper and pencil. Unresponsive or partially
stuporous clients will often write when they fail to talk.
Shows tongue when commanded to do so, moves limbs
grasps with hand when asked to do so.
Reaction to pin-pricks Conclusion: It is of paramount importance that all nurses
working with psychiatric patients should know, understand
V Muscular reactions:
and be skilled in mental status examination. This tool is an
Test for rigidity, muscles are relaxed or tense when asset to all nurses as it aids in diagnosing, formulating nursing
limbs or body is moved. interventions, observing changes and evaluating care. A
Test for negativism shown by movements in opposite nursing teacher also is benefited in that mental status
direction or springy or cog-wheel resistance. examination is not only a clinical tool but also a teaching tool.
It helps the teacher in demonstrating on the patient how to
Test head and neck by movement forward and backward assess presence of psychiatric symptoms. GNM level
as well as to side students gain expertise when they return demonstrate this
Test also the jaw, shoulders, elbows, fingers and the skill to the teacher. Proficiency in this area will further help
lower extremities them to identify and refer psychiatric problems in patients when
they work in the general hospitals, the community, schools,
Does distraction or command influence the reactions?
etc. Teachers teaching psychiatric nursing should definitely
Is there closing of mouth, protrusion of lips, holding of gain clinical skills which will help their teaching to be effective!
saliva, drooling, etc.
VI Emotional responsiveness:
References:
Is feeling shown when talked to about family or children?
1. Folstein MF, Folstein S, Mc Hugh PR, Mini-Mental State:
Or when sensitive points in history are mentioned or
A Practical method for grading the cognitive state of
when visitors come?
patients for the clinician, J.Psychiatr Res 12:189, 1975
Note whether or not acceleration of respiration or pulse
2. Kaplan.I.Harold, Sadock. J. Benjamin, Synopsis of
occurs. Also look for flushing, perspiration, tears in
Psychiatry: Behavioural Sciences/Clinical Psychiatry,
eyes, etc. Do jokes elicit any responses?
B.I.Waverly Pvt. Ltd. , New Delhi, VIIIth Edition, 1998
Effect of unexpected stimuli (clap hands, flash of electric
light)
17

18. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
UNIT - 5 PHYSICAL NEUROLOGICAL EXAMINATION
Dr. Ramachandra
Associate Professor
Dept. of Nursing
NIMHANS , Bangalore-29
Introduction: Moisture-dry, wet or moist?
Assessment is an important component of nursing process. Motion-still or vibrating?
A complete nursing assessment includes both the collection
Consistency of structures-solid or fluid filled?
of subjective data and objective data. The complete health
history is performed to collect as much subjective data about
a client as possible. Objective data include information about iii) Percussion:
the client that the nurse directly observes during interaction
Percussion involves tapping fingers or hands quickly and
with him and information elicited through physical assessment
sharply against parts of the patient's body, usually the chest or
techniques.
abdomen. The technique helps to locate organ borders, identify
1. Physical Examination: organ shape and position and determine if an organ is solid
Four basic techniques must be mastered before professional or filled with fluid or gas.
can perform a thorough and complete assessment of the Percussion requires a skilled touch and trained ear to detect
client. By using a systematic approach, examiner will less slight variations in sound. Organs and tissues, depending on
likely to forget an area. their density, produce sounds of varying loudness, pitch and
Four techniques used are: duration. For instance, air-filled cavities, such as the lungs,
i) Inspection. produce markedly different sounds than do the liver and other
dense tissues.
ii) Palpation.
iii) Percussion. The examiner has to move gradually from areas of resonance
to those of dullness and them compare sounds. Also, compare
iv) Auscultation.
sounds on one side of the body with those on the other side.
iv) Auscultation:
i) Inspection:
Auscultation, usually the last assessment step, involves
Inspection involves vision, smell and hearing to observe
listening for various breath, heart and bowel sound with a
normal conditions and deviations. Performed correctly,
stethoscope. To prevent the spread of infection among
inspection can reveal more than other techniques.
patients, clean the hearts and end pieces of the stethoscope
Inspection begins from first meeting with the patient and with alcohol or a disinfectant after every use.
continues throughout the health history and physical
2. History
examination. As the examiner assess each body system,
observe for color, size, location movement, texture, symmetry, A thorough and accurate history of a neuro patient is often very
odor, and sounds. helpful in assessing their condition. The character of
symptoms, distribution, temporal profile of symptoms,
ii)Palpation
epidemiological associations are often needed in detail in
Palpation required examiner to touch the patient with different neurological patients in comparison to other general diseases.
parts, using varying degrees of pressure. To do this, examiner The fact that in neurological patients their cerebral dysfunction
need short fingernails and warm hands. Always palpate tender may limit or distort the account of history third party sources of
areas last. Information about the purpose of touch to different information are most often needed.
parts is essential.
3. Neurologic Examination
Evaluation of the following features are required:
Neurological assessment is one of the key components of
Texture-rough or smooth? nursing practice. It plays a pivotal role in localization of the
Temperature-warm, hot or cold? problem. It encompasses history collection, and the physical
examination. Observation is the most important key for
18

19. Booklet on Psychiatric Nursing Skills toTeachers of School of Nursing
neurological assessment. The exam ination requires skill and Make a note of the age, height, build and weight. Is the
patience, from the examiner. patient obese or cachectic?
A thorough neurologic examination may take 1 to 3 hours; Check the vital signs including temperature, pulse,
however, routine screening tests are usually done first. If the respiratory rate and blood pressure.
results of these tests raise questions, more extensive Level of consciousness
evaluations are made. Three major considerations determine
Glasgow coma scale is an objective method to assess the
the extent of a neurologic examination:
level of consciousness in the patients with neurological
a. The client's chief complaints disorders. This scale describes conscious level in terms of
b. The client's physical condition (i.e., level of eye opening, verbal response and motor response. These
consciousness and ability to ambulate), as many parts are having 4, 5, 6 scores each respectively. On examination,
of the examination require movement and coordination observer has to assign score to the observed category to each
of the extremities parameter. The minimum score is 3 and maximum is 15.
c. The client's willingness to participate and cooperate.
Eye Opening (E) Verbal Response (V) Motor Response (M)
4= spontaneous 5= oriented 6= obeys commands
3.1 Equipments required are 3= to voice 4= disoriented conversation 5= localizes pain
2= to pain 3= non comprehensible 4= withdrawal flexion
1. Reflex hammer
1= no response words, 3= abnormal flexion
2. 128 and 512 hz tuning forks 2= incoherent sounds decorticate posture
1= no response 2= abnormal extension
3. Snellen Chart decerebrate posture
4. Pen light 1= no response
5. Ophthalmoscope
6. Sugar/salt For children under 5, the verbal response criteria are adjusted
as follow
7. Coffee powder/any scented material
8. Disposable safety pin Score 2 to 5 yrs 0 to 23 months
appropriate words or
9. Tongue depressors 5 smiles or coos appropriately
phrases
10. Wisps of cotton to assess light- touch 4 inappropriate words cries and consolable
persistent cries and/or persistent inappropriate
11.T est tubes of hot and cold water for skin temperature 3
screams crying /or screaming
assessment grunts or is agitated or
2 grunts
restless
1 no response no response
3.2 The components of neurological examination includes
assessment of:
Children with a Glasgow Coma Scale of 3-8 are considered
1. Level of consciousness 5.Sensory System. comatose
2. Mini Mental Status Exam 6. Deep tendon reflexes 3.4 Mental Status Examination
3. Cranial nerves 7.Coordination and balance Evaluation of mental status is a part of the neurological
4. Motor System 8. Brain stem reflexes examination. The appearance, behaviour, level of
consciousness, attention, concentration, memory, orientation,
abstraction, judgement, language and speech are assessed
3.3 Assessment of Level of consciousness as discussed in earlier chapter
General appearance: 4. Examination of the Cranial Nerves
Note the patient's personal hygiene and dress. Is it appropriate The following is a summary of the cranial nerves and their
for the environment situation or not respective functioning.
19