Psychiatric Diagnosis and Management Reflective Journal
Mental disorders and illnesses are the leading causes of compromised quality of life, a high prevalence of suicidality and self-harm, significant distress, and impairment in functioning, resulting in disabilities. According to the World Health Organization [WHO] (2022), about 970 million (1 in every 8 people) had mental disorders in 2019.
In 2020 and 2021, the prevalence of mental disorders, such as depression, bipolar disorder, and disruptive and dissocial behaviors rose significantly due to the adverse consequences of the COVID-19 pandemic. Psychiatric health nurse practitioners (PMHNPs) have ideal opportunities alongside the ethical and professional responsibility to play a forefront role in improving child, adolescent, and adult mental health (Kumar et al., 2020).
Strategies implemented by PMHNPs to improve the population’s mental health include early mental status examination, recommendations on pharmacologic and non-pharmacologic interventions, and evidence-based practices for enhancing safe-management competencies.
Therefore, this paper aims to reflect on my practice as a psychiatric mental health nurse practitioner (PMHNP), identify parts of the mental status exam that I am most and least confident with, and elaborate on a plan for improving confidence when doing a mental status exam.
Reflection on My Practice as a Psychiatric Mental Health Nurse Practitioner (PMHNP)
As a psychiatric mental health nurse practitioner, I have had ideal opportunities to translate theoretical knowledge to clinical practice and real-life situations. Before delving into in-depth contentions regarding these opportunities, it is valid to argue that psychiatry as a clinical specialty is one of the most complex fields of specialization, considering the prevailing chasms between patients’ involvement in care practices and their ability to make informed decisions.
According to Varkey (2018), clinicians have legal, professional, and ethical obligations to benefit patients, avert harm, uphold patient autonomy, and respect their values, preferences, and decisions. These responsibilities form the basis of the four bioethical principles: beneficence, non-maleficence, autonomy, and justice.
Although the four bioethical principles enshrine the universally accepted behaviors and expectations for clinicians, psychiatric mental health nurse practitioners face unique challenges when providing evidence-based, patient-centered, and dignified care to patients with mental health conditions, especially progressive mental illnesses, such as schizophrenia and Alzheimer’s Disease (AD).
According to Joubert & Bhagwan (2018), the common challenges facing psychiatric nurse practice include patients’ denial of the underlying mental conditions, psychiatric patients’ unpredictive behaviors, exposure to patient aggression and violence, and resource limitations. Equally, psychiatric mental health nurse practitioners face an uphill task when complying with the ethical obligation of upholding patient autonomy in deciding care trajectories.
Often, psychiatric patients demonstrate a progressive decline in cognition and the deterioration of critical thinking and decision-making competencies. These factors hinder the norm of reserving decision-making autonomy to patients.
Amidst the prevailing challenges in the psychiatric specialty, I have had opportunities to familiarize myself with essential steps for providing quality and individualized care to a patient with different mental health conditions, including depression, post-traumatic stress disorder (PTSD), unresolved childhood trauma, schizophrenia, Alzheimer’s Disease (AD), and bipolar disorder.
One of the competencies acquired during my practice as a psychiatric mental health nurse practitioner is the implementation of various therapeutic interventions for alleviating the effects and complications associated with mental disorders. Examples of these therapeutic approaches include mindfulness-based cognitive therapy (MBCT), eye movement desensitization and reprocessing (EMDR), cognitive behavioral therapy (CBT), exposure therapy (ET), counseling, and psychoanalysis and psychodynamic therapies.
The knowledge and awareness of these therapies enable me to change patients’ problematic behaviors, feelings, and thoughts and condition positive perceptions and actions to reduce the prevalence and implications of mental health conditions.
Besides understanding and practicing universally accepted psychological and behavioral therapies, I have acquired knowledge regarding the clinical manifestations of different mental health disorders. For instance, I have had opportunities to provide direct care to patients with mental disorders like post-traumatic stress disorder, depression, and stress. Therefore, I can effectively classify mental disorders by observing patients’ behaviors, motor activities, appearance, speech, mood, and thought processes.
The first-hand encounter with different patient conditions and situations has significantly enabled me to familiarize myself with the most common forms of mental health conditions and their respective signs and symptoms. Before qualifying as a psychiatric mental health nurse practitioner, I was a novice in the psychiatric specialty, meaning that I had no experience with situations and relied on textbook rules due to the absence of contextual meaning to apply in different clinical and patient situations (Nyikuri et al., 2020).
As a competent psychiatric mental health nurse practitioner, I can exercise deliberate conscious planning, make long-term plans, and demonstrate efficiency and organization when delivering care to patients with mental disorders.
Finally, I have acquired knowledge and awareness of various strategies for conducting mental status exams. According to Voss & Das (2021), the mental status examination is the psychiatric version of a physical examination. In this sense, the major aims of examining patients’ mental statuses include defining their situations during evaluation, describing aspects of their mental health, and informing patient-centered care interventions.
In the same breath, Bharuchi & Rasheed (2022) contend that mental status examination enables psychiatrists to recognize disruptions in patients’ mood, cognitive performance, and functional issues. As a result, they can implement evidence-based approaches for reducing anxiety and negative emotions in hospitalized patients with mental disorders.
In the context of conducting a mental status examination, psychiatrists have plenty of options to consider and various themes for exploration. As a psychiatric mental health nurse practitioner, I have participated in collaborative efforts and interdisciplinary approaches for assessing patients’ mental status consistent with various examination parts, including appearance, behaviors, motor activity, speech, mood, thought process, thought content, perceptual disturbances, insight, judgment, and cognition.
Due to these examinations, I have realized that mental disorders uniquely affect patients’ behaviors, cognition, decision-making, critical thinking competencies, motor activity, mood, speech, affection, and perceptions. As a result, I can effectively categorize mental disorders consistent with the effects of these themes of mental status examination.
Finally, the opportunity to conduct a mental status examination has enabled me to identify the parts with which I am most and least confident. Consequently, I can develop an informed plan for bolstering confidence when examining patients’ mental status.
What parts of the mental status examination that I am most confident with?
The mental status examination (MSE) is synonymous with physical examination in other clinical specialties. Blaabjerg et al. (2019) contend that MSE is a crucial function of the psychiatrist assessment because it focuses on observed phenomena instead of patient history. It is essential to note that understanding the pathophysiology of mental health conditions is essential in inspiring evidence-based and individualized treaties and management interventions.
When conducting mental status examinations, psychiatrists examine various parts and their subsequent observed phenomena, including appearance, behaviors, motor activity, speech, mood, affection, thought process, cognition, and perceptions.
When examining patients’ appearance, psychiatrists apply interventions to observe clients’ overall grooming, hygiene, mark depictions, and other aspects of the general appearance that can provide clues for the presence or absence of mental health conditions. Secondly, behavioral examination entails assessing patients’ cooperation, agitation, discomfort, and resistance to comply with mental status exams (Voss & Dass, 2021).
Thirdly, motor activity examination can reveal the presence of psychomotor retardation, catatonia, hyperactivity impulsively, and akathisia. Affection and mood examination can unearth the underlying feeling and expressions, including happiness, sadness, agitation, anxiety, and euphoria (Voss & Dass, 2021).
Finally, cognition, insight, and judgment exams can expose the effects of mental disorders on an individual’s decision-making competencies, memory, attention and concentration, and awareness of the surroundings and situations (orientation). Based on these themes of mental status examination, psychiatrists can categorize mental illnesses and implement informed interventions to avert further complications associated with mental disorders.
Although there are multiple assessment tools and scales for examining patients’ behaviors, moods, cognition, judgment, and insights, they narrow down to interviews and questionnaires designed to obtain feedback from patients. As a psychiatric mental health nurse practitioner (PMHNP), I am more confident when examining clients’ appearance, motor activity, affect, perceptions, cognition, and judgment.
The reason for being confident with these parts of the mental status examination is their simplicity and reduced probability of triggering unpredictive behaviors and reactions to the assessment items, including questions. By using questionnaires and direct observation, I can effectively examine patients’ appearances, their level of cognition, quality of judgment and insights, and their perceptions of the presence of mental health conditions.
What parts of the mental status exam that I am least confident with?
Although I have had opportunities to conduct mental status exams, I am least confident with various parts, including behavior, mood, speech, and thought consent. My concern when examining these themes is the probability of encountering unpredictable behaviors and acts, including violence, among patients with mental health conditions. For example, it is essential to test patients’ agitation, avoidant, refusal to talk, and level of cooperation when examining their behaviors (Voss & Dass, 2021).
Equally, assessing the patient’s acceptance or denial of suicidal thoughts, nightmares, hallucinations, and incidences of reminiscing past events is vital when testing their thought consent. As a result, asking sensitive questions increases the likelihood of retaliation, invoking negative responses, and violent behaviors from agitated patients.
What is my plan for shoring up confidence when conducting a mental status exam?
Although I am least confident with behavior, speech, and thought consent exams, I must inevitably conduct them during my practice to examine the presence or absence of mental disorders. As a result, it is essential to enhance confidence when conducting these examinations.
The first strategy for shoring up confidence in these parts of mental status exams is proper documentation and recording of findings consistent with the three aspects of mental health examination. According to Soltan & Girguis (2017), it is vital to effectively record a patient’s body language and related aspects like maintaining eye contact, body posture, abnormal movements, and behaviors towards the examination practice. A close evaluation of these aspects is vital in identifying potentially aggressive behaviors and avoiding violence when conducting mental status examinations.
Secondly, it is possible to improve confidence when conducting these parts of mental status examination by implementing non-pharmacologic interventions for violent and aggressive patients. Adeniyi & Puzi (2021) contend that approaches to addressing aggression and violence in patients with mental disorders narrow down to three broad categories: pre-event, during the event, and post-event. Pre-event measures include effective communication, providing patient guidelines, and establishing expectations of conducting the mental status examination.
Secondly, during event, approaches include communicating unacceptable behaviors, requesting security assistance, isolating perpetrators, and obtaining feedback from patients to understand the cause of aggressiveness and violence (Adeniyi & Puzi, 2021). Finally, post-event actions include recognizing triggers, reviewing responses, initiating alerts or warnings, and follow-up activities.
Although mental disorders are the leading cause of disability, compromised quality of life, and suicidal thoughts and activities of self-harm, psychiatric mental nurse practitioners must improve the population’s mental health by implementing evidence-based practice and population-oriented interventions.
As a psychiatric mental health nurse practitioner, I have had opportunities to provide individualized care, including conducting mental status examinations and recommending pharmacologic and non-pharmacologic approaches. In this sense, I can effectively examine patients’ appearances, cognition, judgment, thought consent, and perceptions.
However, I am least confident with behavior, speech, and mood examination due to the probability of encountering unpredictable behaviors and acts like violence when examining these parts. Therefore, I can enhance my confidence in these themes by effectively recording findings and implementing pre-event, during-event, and post-event measures for aggressive and violent patients.
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Bharuchi, V., & Rasheed, M. A. (2022). Development and feasibility testing of the mental status examination scale to assess the functional status of young, hospitalized children in Pakistan. SSM – Mental Health, 100126. https://doi.org/10.1016/j.ssmmh.2022.100126
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