By Day 6 of Week 2
Respond to at least two of your colleagues on 2 different days by comparing your assessment tool to theirs.
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Examining, assessing, and diagnosing the client are all important aspects of being a psychiatric mental health nurse practitioner. Becoming skilled and confident in these areas helps providers to develop appropriate and effective treatment plans. One thing that has been emphasized in our reading this week and last week is the client-provider relationship. The initial assessment is where the provider lays the groundwork for developing a positive rapport. Sadock et al. (2015) stated one of the crucial aspects of the examination is showing empathy while retaining objectivity. Providing privacy, confidentiality, respect, and comfort are significant factors in the assessment process. American Academy of Child and Adolescent Psychiatry (1995) recommended that providers approach the interview with three things in mind: to obtain a diagnosis, determine if treatment will be indicated, and develop a treatment plan to keep the client engaged. One of the objectives of this class is to feel confident with assessment tools and decide which ones are appropriate for which clients. This post will discuss three important components of the psychiatric interview. NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales Discussion I will also discuss the Positive and Negative Symptom Scale (PANSS) and how the provider uses it to determine appropriate diagnoses and treatment.
The psychiatric interview, an examination or assessment, is complex and time-consuming. The process can still take around an hour with a cooperative client. Three crucial components of the interview include the social history, family history, and past medical history NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales Discussion. The social history gives the provider vital information about how the client functions and what kinds of coping skills they currently employ. This part of the interview also allows the provider to assess the client’s use and history with illicit drugs and alcohol. Sadock et al. (2017) recommended approaching this section of the interview carefully, as the provider will need honest information to get a clear picture of the client’s situation. Asking questions about substance use and abuse should be done without judgment. This tactic includes tone of voice, inflection, and body language. This information is critical in determining which symptoms could be related to substance abuse and which treatment would be most appropriate for each client. An example would be a client who presents with attention deficit disorder and reveals that they have a history of meth use. In this case, the provider would probably want to steer away from effective medications such as Adderall due to the possibility of abuse NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales Discussion.
Many psychiatric disorders have a genetic component that can be assessed during the interview’s familial history portion. The provider can use this information to determine an accurate diagnosis and treatment. For example, if a client came in complaining of symptoms that seemed to align with anxiety and then stated that her mom, sister, aunt, and grandmother had all been diagnosed with anxiety, the client likely has a genetic predisposition for that disorder. Because genetics can also affect how successful treatment is, so it could be useful to know how the client’s family responded to it. Another significant part of the family history is the history of suicide attempts and aggressive behaviors. American Psychiatric Association (2016) found that a family history of suicidal ideation and aggression puts the client at higher risk for the same behaviors. As a provider, I would use this information to focus a few more questions in these areas for a clearer picture of my client’s situation.
A client’s past medical history is important for a variety of reasons. A medical history can give the provider insight into possible risk factors for mental disorders. It also will affect how the provider develops a treatment plan. American Psychiatric Association (2016) stated that the provider would also need to determine how any current medical conditions could affect the presentation of symptoms and how that will influence the diagnosis. An example of this could be head injuries. The medical history is also important because it will cover any allergies or drug sensitivities the client may have had in the past. Providers use this information when developing their treatment plan if it includes medications. Another crucial component of the medical history is the current medications and supplements the client is taking. The provider must ensure that anything they propose to add to the client’s regimen will not cause adverse effects. Lastly, a past medical history gives the provider insight into other professionals they can collaborate with regarding the client. The client’s physical health is important and should be monitored while receiving psychiatric treatment. NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales Discussion
One tool that can be used during a psychiatric interview is the PANSS. This tool is used to determine the severity of the disorder and the client’s quality of life. Once the diagnosis of schizophrenia is decided on, this tool can be used to determine the direction of effective treatment. Therefore, this tool is only used at the end of an interview and only when the client has been appropriately diagnosed with schizophrenia. The symptoms of schizophrenia are classified as positive and negative. Positive symptoms include things like hallucinations, delusions, paranoia, and grandiosity. Negative symptoms include social withdrawal, blunted affect, difficulty communicating with a natural flow, and apathy. This assessment can take up to 45 minutes, so it may be beneficial to schedule a time to perform this assessment after the first consultation and diagnosis are complete. Depending on the client’s condition, the provider should also plan to include caregivers during the evaluation and information gathered from previous providers. The client is rated in 30 different areas, from one to seven. The areas are broken down into positive symptoms, negative symptoms, and general psychopathology NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales Discussion. There is a PANSS-6 that only assesses six of the core symptoms of schizophrenia and a Simplified Negative and Positive Symptoms Interview (Kølbæk et al., 2018). These could be used instead of a more detailed assessment if time were a factor. One study I researched found that vitamin D levels directly correlated to the PANSS score. Prasanty et al. (2018) stated that the lower the vitamin D level, the higher the PANSS score. Ordering a vitamin D level would be worthwhile when treating a client with schizophrenia.
Psychiatric interviews should be client-centered, and the treatment should reflect the client’s goals, not the provider’s (Sadock et al., 2015). Client-centered interviews and treatment focus on the client’s strengths, culture, and areas identified by the client that need work. Providers should take the interview as an opportunity to begin a solid foundation of collaborative decision-making between them and the client. Open-ended questions are helpful at the beginning of the interview, with more focused questions used to clarify the information required to determine differential diagnoses and treatments. Prioritizing the client’s symptoms and diagnoses will also be an important aspect of the assessment because many clients have comorbid conditions. The client’s social history, family history, and past medical history are crucial aspects of the psychiatric interview. NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales Discussion
References
American Academy of Child and Adolescent Psychiatry. (1995). Practice parameters for the assessment and treatment of children and adolescents. https://www.aacap.or/App_Themes/AACAP/docs/practice_parameters/psychiatric_assessments_practice_parameter.pdf
American Psychiatric Association. (2016). Practice guidelines for the psychiatric evaluation of adults. (3rded.). https://psychiatryonline.org/doi/pdf/10.1176/appi.boooks.9780890426760
Kølbæk, P., Blicher, A. B., Buus, C. W., Feller, S. G., Holm, T., Dines, D., O’Leary, K. M., Sørensen, R. S., Opler, M., Correll, C. U., Mors, O., Bech, P., & Østergaard, S. D. (2018). Inter-rater reliability of ratings on the six-item Positive and Negative Syndrome Scale (PANSS-6) obtained using the Simplified Negative and Positive Symptoms Interview (SNAPSI). Nordic Journal of Psychiatry, 72(6), 431–436. https://doi-org.ezp.waldenulibrary.org/10.1080/08039488.2018.1492014
Prasanty, N., Amin, M. M., Effendy, E., & Simbolon, J. (2018). Low vitamin D serum level increases severity symptoms in schizophrenic patients measured by Positive and Negative Symptoms Scale (PANSS) in Batak Tribe Sumatera Utara, Medan-Indonesia. Bali Medical Journal, 7(1), 249-254. https://doi-org.ezp.waldenulibrary.org/10.15562/bmj.v7i1.921
Sadock, B. J., Sadock, V. A., & Ruiz, P. (2015). Kaplan & Sadock’s synopsis of psychiatry(11thed.). Philadelphia, PA: Wolters Kluwer.
Sadock, B. J., Sadock V. A., & Ruiz, P. (2017). Kaplan and Sadock’s concise textbook of clinical psychiatry (4thed.). Philadelphia, PA: Wolters Kluwer. NRNP 6635 The Psychiatric Evaluation and Evidence-Based Rating Scales Discussion