psychosocial assessment

1 Running head: PSYCHOSOCIAL ASSESSMENT Psychosocial Assessment Nurs-386-002 Prof. Mrs. Patricia Bowie State University May 13th, 2018 Introduction 2 PSYCHOSOCIAL ASSESSMENT Mental illness has become a public health crisis due to severe shortage of inpatient care as result of increment in the number of people suffering from mental health disorder. The CDC (2013) reports that about 25% of American adults suffers from some forms of mental disability. This described the extent of mental illness in the American adult population and thus increased the effort of nurses and other health practitioners to monitor mental health and come up with the best approach in their assessment of client and care. Nurses and other health care workers use this tool (psychosocial assessment) to

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evaluate individuals’ social well-being and mental health. It also assesses the individual’s ability to thrive well in the society and self-perception. During this process, the healthcare worker tries to understand the individual and his or her domain by asking sequence of questions related to that person. This help the health care provider to provide the best care possible to obtained optimal health which is the goal of psychosocial assessment. This psychosocial assessment paper is on Mr. R.B., who is an African American currently hospitalized for schizophrenia at Spring Grove Hospital Center (SGHC). This paper looks at his culture, social, legal, education, occupation, financial, spiritual and psychiatric history as well. Also, it involves Mini Mental Status Examination (MMSE), a full mental assessment and DSM-V diagnoses to evaluate client illness and overall health. Nursing diagnosis are famulated based on client assessment data. Planning and interventions are carried out and the effectiveness of interventions are evaluated. A meta-analysis of age onset of schizophrenia is observed, and a bibliography is provided. The etiology of schizophrenia, signs and symptoms, and clinical manifestations. 3 PSYCHOSOCIAL ASSESSMENT Social Assessment Mr. R.B is a 26-year-old Asian who was admitted to Spring Grove Hospital center (SGHC) for schizophrenia. He verbalized of leaving with his mother and was asked out of the house when a marijuana was found in the house by his mother. He was homeless for sometimes. Moreover, he went to jail for stealing a delivery van that was parked along a gas station. A worker in that gas station called a police officer who took patient to prison. His life in prison was horrible, as he was observed pouring food on his head and drinking from the bathroom tap. He alleged of completing high school and started a community college and did not finish. Also, he used to work in a local pizza shop, and sometimes do delivery. Additionally, patient denied of hurting self or peers, however, he was on a 72-hour suicidal watched per chart. Although he denies hearing voices, but records showed he admit receiving messages from the television. His mother visits him once a week. Patient asserted of having at least 9 hours sleep most nights, good appetite, and constipated (“I don’t have bowel movement for 3 days and more”). Socially, he smokes 2-3 sticks of cigarette per day during his smoke break, had a history of substance abuse, sexual, and physical abuse as well. Moreover, he stopped the interview process and went to his bedroom at 11:00 AM. Patient stated that, “I don’t want to associate myself with people in this unit that is the reason why most times I have my head set on listening to music.” Client performs activity of daily living (ADLs) with less supervision. He does not like to do his laundry, and can use the restroom, feed himself, clean his bedroom with more supervision. Furthermore, patient is a Christian who believes in God and pray for his family most times at night. Due to his status, he is not allowed to go to the cafeteria or go to Church on Sundays. 4 PSYCHOSOCIAL ASSESSMENT Psychiatric history Patient stated his mental illness started when he was 19 years old, and his first admission was in Spring Grove Hospital Center. When asked about his past medical history, he denies any history of inpatient hospitalization, however, his chart indicates he was admitted to Fairfax Hospital in Virginia and was on medications for auditory hallucinations, delusion, and hypothyroidism. Patient alleged of no history of mental illness in his family. His condition was deteriorating using illicit drugs accompanied by medication noncompliance, and homelessness. This made his condition to be worsened until she was arrested for stealing a delivery van in 2017 which paced his way to jail. According to his chart, the police report stated that patient was at a gas station begging for coins which the cashier at that gas station reported as sometime that has been going on since. Eventually, he breaks into someone’s delivery van and the cashier saw him from a distance and called a police officer. In the detention center and in the court room, report indicates that patient exhibited delusional statements, disorganized speech, and agitated behavior. When patient was question about the incident he responded to the police officer that, “I am the owner of the van.” In the hospital, patient chart indicates that he was displaying aggressive behavior, easily bothersome to his peers, so he was prescribed Olanzapine 7.5 mg PO bid for his psychosis, Risperidone 4mg PO bid for his mood, and Strattera 18mg PO bid for attention by the clinical review team. Patient behaviors did not change with these medications; thus, lorazepam 2mg PO bid and valproic acid liquid 500mg PO Q12h were added to his treatment regime which shown gradual improvement in patient’s psychosis and agitation. However, he was transferred to another unit where patient can smoke cigarette, watch tv, and used a computer to browse on Fridays. When patient was asked how he purchase cigarette while in the unit with red wrist band, 5 PSYCHOSOCIAL ASSESSMENT he stated “they take my blood as a specimen for an experiment and give him $20 which I used to buy my cigarette and sometimes order Chinese food. Mini Mental Status Examinations (MMSE) Mini –mental state assessment was administered to Mr. R.B. on April 26th, 2018. He was unable to tell the season of the year to be spring but was able to tell the date, day month and the year. He was able to tell the state to be Maryland and the town to be Baltimore, tell the name of the hospital and the unit in which he is currently staying. I named out three objects; pencil, book, and telephone and asked him to repeat them. In the first and second trial, patient was able to repeat only the telephone which gives patient a score of 1. Patient was able to repeat the book and pencil in the third trial and all the words in the fourth trial. To assess attention and calculations, patient was asked to first begin with 100 and count backward by seven which he could not do, so he was asked to spell the word “Earth” again, patient could not perform this task. Five minutes after patient was asked to repeat the words; pencil, book and telephone, patient was now asked to recall those words, but he was unable to do it, so he scored zero. To assess patient use of language and praxis, patient was shown a coin and a crayon and was asked to name them. He was able to name them, so she scored 2 points. The sentence “I brush my teeth every morning” was read and patient was asked to repeat it and he correctly repeated it which he score 1 point. A piece of paper was put on patient’s lap and patient was asked to take it with his right or left hand, fold it into half and place it on the floor. Patient scored 3 points for completing each step of the command. I wrote “Close your eyes” on a paper and asked patient to perform what he reads. Patient closed both eyes which gave him a score of 1. Furthermore, patient was asked to write a sentence about anything. Patient wrote “I want to take my smoke 6 PSYCHOSOCIAL ASSESSMENT break” which gave a score of 1. Lastly, he was given a picture of two interlocking heptagon and was asked to draw the picture on a blank sheet of paper. Patient was able to draw it in about 4 minutes and scored 1 point. The individual scores were added, and patient scored a total of 12 points. Based on patient score, he is considered severely cognitively impaired. Mental status Examination Patient was casually dressed in a red hoodie and a blue jean pant with an orange slipper. He appears normal weight and poorly groomed with dry feet, long toenails and unshaven hair. Patient is cooperative and friendly. Speech is rapid, loud and talkative. He displays dysphoric mood, and affect is flat, restrictive, labile and mood congruent. Flat affect is more pronounced when he tries to recall the response to a question. Patient presents a negative body image and low self-esteem as he stated that, “I never got a girlfriend because nobody will date me.” He is oriented to person and place, time and he shows recent and immediate recall deficit. Patient possesses loose association of thought and redirection seems to be less effective. He presents a monotonous stereotypical thought about Mexicans (“Mexicans are very bad people”). He possesses a persecutory delusion as he continuously says, “Mexicans always carry gun trying to kill people”. He denied any form of hallucination and any thought of harm to self or others, per chart he suffers auditory hallucination sometimes. 7 PSYCHOSOCIAL ASSESSMENT Laboratory Values LAB Result: 02/20/18 at 4:20 PM Normal Value Serum Glucose 86 mg/dL 65-99 mg/dL BUN 11 mg/dL 6-20 mg/dL Serum Creatinine 0.87 mg/dL 0.76-1.27 mg/dL BUN/Creatinine Ratio 13 9-20 Serum Sodium 142 mmol/L 134-144 mmol/L Serum Potassium 4.4 mmol/L 3.5-5.2 mmol/L Serum Chloride 99 mmol/L 96-106 mmol/L Total CO2 26 mmol/L 18-29 mmol/L Serum Calcium 9.8 mg/dL 8.7-10.2 mg/dL Total Serum Protein 8.2 g/dL 6.0-8.5 g/dL Serum Albumin 4.4 g/dL 3.5-5.5 g/dL Total Bilirubin 0.3 mg/dL 0.0-1.2 mg/dL AST 20 IU/L 0-40 IU/L ALT 19 IU/L 0-44 IU/L Total Cholesterol 175 mg/dL 100-199 mg/dL TG 327 mg/dL 0-149 mg/dL HDL 27 mg/dL >39 LDL 83 0-99 WBC 6.7 3.4-10.8 x10E3/uL Hemoglobin 16.1 g/dL 13.0 – 17.7 g/dL 8 PSYCHOSOCIAL ASSESSMENT Hematocrit 46.2% 37.5-51.0% Platelets 260 150-379 x10E3/uL DSM-V Diagnoses DSM Description Observed Behaviors Treatment V Axis I Primary • History of psychosis • Behavior therapy psychiatric • History of initial • Olanzapine ODT 7.5mg PO disorder • noncompliance with the Q12H. for aggressive and medications psychosis. Ongoing delusions • Valproic Acid Liquid 500mg PO Q12H • Lorazepam 2mg tabs. PO TID for worsening catatonia. • Diphenhydramine 50 mg PO PRN for Insomnia and aggression. 9 PSYCHOSOCIAL ASSESSMENT Axis II deferred N/A N/A Axis Medical III • constipation • • Hypothyroidism • Hyperammonemia • GERD juice or water q. a.m. for • High Triglyceride constipation Docusate sodium 100mg m Q24H for constipation • • MiraLAX 17g in 8 ounces of Levothyroxine 25mcg PO Q24H. • Malox 30ml PO Q24H for dyspepsia. • Levocarnitine 33omg PO TID for increase serum ammonia level. Axis Psychosocial IV Stressors Axis V GAF • Omega 3 fish oil IG PO Bid • Social Services Unemployed, minimal family • Counseling support. • Therapy GAF 55 N/A 10 PSYCHOSOCIAL ASSESSMENT Nursing Diagnoses 1. Deficient diversional activity related to social isolation as evidenced by patient’s statement, “I don’t want to associate myself with people in this unit that is the reason why most times I have my head set on listening to music.” 2. Disturbed thought process related to uncompensated alteration in brain activity as evidence by patient’s delusional thinking of “Mexicans are bad people they always carry guns trying to kill people.” 3. Disturbed personal identity related to perceived prejudice as evidenced by patient’s statement of “Mexicans are bad people they always carry guns trying to kill people.” 4. Ineffective coping related to inadequate support system as evidenced by patient’s minimal family support. Nursing Diagnosis #1: Risk for suicide related to history of suicide attempt as evidenced by patient’s 72-hour suicidal watched per chart. Planning Patient will disclose and discuss suicidal ideas if present by the end of the shift. Interventions 1. Assess for suicidal ideation when the history reveals the following: schizophrenia and substance abuse. 2. Assess client’s ability to enter into a no-suicide contract either verbally or writing. 11 PSYCHOSOCIAL ASSESSMENT 3. Take suicide notes very seriously and ask if a note was left in any previous suicide attempts. 4. Determine the presence and degree of suicide risk. 5. Develop a positive therapeutic relationship with patient; do not make promises that may not be kept. 6. Place the patient in the least restrictive, safe, and monitor environment that allows for the necessary level of observation. Evaluation Intervention was not effective will continue current intervention or change as needed. Nursing Diagnosis #2: Risk for other – directed violence related to agitation as evidenced by patient aggressive confrontation on peers. Plan: Patient will display no aggressive activity by the end of the shift. Intervention: 1. Assess causes of aggression: social versus biological. 2. Act to minimize personal risk; use nonthreatening body language, and respect personal space and boundaries. 3. Remove potential weapons from the environment. 12 PSYCHOSOCIAL ASSESSMENT 4. Inform the patient of unit expectations for appropriate behavior and the consequences of not meeting these expectations. 5. Redirect possible violent behaviors into physical activities (e.g. walking, jogging) if the patient is physically able. 6. Measures of violence may be useful in predicting or tracking behavior and serving as outcome measures. Evaluation: Intervention was not effective will continue current interventions or change as needed. Nursing Diagnosis #3: Disturbed thought process related to uncompensated alteration in brain activity as evidence by patient’s delusional thinking of “Mexicans are bad people they always carry guns trying to kill people.” Plan 1. Patient will be able to differentiate between delusional thinking and reality. Intervention 1. Communicate your acceptance of patient’s need for the false belief, while letting him know that you do not share the belief. 2. Teach patient to intervene, using thought-stopping techniques, when irrational or negative thoughts prevail. 13 PSYCHOSOCIAL ASSESSMENT 3. Do not disagree or deny the patient’s belief. Use reasonable doubt as a therapeutic technique: “I understand that you believe this is true, but I personally find it hard to accept.” 4. Help patient try to connect the false beliefs to times of increased anxiety. Discuss techniques that could be used control. 5. Reinforce and focus on reality. Discourage long ruminations about the irrational thinking. Talk about real events and real people. 6. Assist and support patient in his attempt to verbalize feelings of anxiety, fear, or insecurity. Evaluation: 1. Intervention was not effective. will continue current intervention or change as required. Etiology of schizophrenia According to Boyd (2015), Schizophrenia is believed to be caused by the interaction of a biological predisposition or environmental stressor. Also, Al-Asmari and Kahn (2014) talked about schizophrenia as a mental illness that described a distortion in someone’s thinking, hallucinations, and reduced ability to feel normal emotions. Immunity, environment, and hereditary factors has long been associated with the disease. Nevertheless, inflammation, substance abuse, stress, brain changes, and neurotransmitters have recently link with the cause of schizophrenia (Hüfner et al, 2015). Furthermore, Psychosocial stress also play role in the etiology of schizophrenia. In a cross-sectional studies study by Larson (2012), Young people with first episode of psychosis are at high risk of developing chronic schizophrenia, possibly the most disruptive of mental 14 PSYCHOSOCIAL ASSESSMENT illnesses. Psychotic symptoms such as hallucinations, delusions, disorganized thoughts, and negative symptoms profoundly influence quality of life, relationships, and daily functioning. There is consistent evidence that patients with schizophrenia experience more stressful life than healthy people. However, there is a significant increase in the events of life preceding psychotic relapse. This becomes chronic when patient sees the even as stressful, uncontrollable or poorly managed. Also, people affected with psychosis and their first-degree relatives are more reactive to daily stress than the average person. Hence, stress plays a key role in the schizophrenia. Another cause of schizophrenia is Substance abuse. Schizophrenia is more prevalent among people who use drugs like marijuana and heroin than nondrug users. Tetrahydrocannabinol is one of the active chemical in marijuana that is known to increase both negative and positive symptoms of schizophrenia. Marijuana use is linked with increase relapse and poor clinical outcome among schizophrenic patients (Larson et al, 2012). Additionally, changes in brain volume also contribute to the cause of schizophrenia. Study shows that schizophrenic patients have low level of hippocampus and temporal regions, and decreased frontal functioning, and increased pituitary level, and overall reduction in cortical gray mater level which accounts for the first and chronic episodes of schizophrenia (Larson et al, 2012). Moreover, there is an evidence that deviations in cytokines could give rise to schizophrenia. research concerning the role of cytokines in schizophrenia has also been expanded. When there is an imbalance in the mechanisms of the immune, endocrine, and neurotransmitter systems will cause cell loss and therefore decrease neurogenesis. Hypothetically, changes in the levels of cytokines can simply be a significance of mental stress or sleep deprivation associated with the onset or exacerbation of schizophrenia. Also, impaired 15 PSYCHOSOCIAL ASSESSMENT antioxidant defense and increased media striatum may cause schizophrenic (Al-Asmari & Khan, 2014). Dopamine, and glutamine are the two neurotransmitters known to be responsible for schizophrenia. There is high dopamine receptor blockage in people affected by schizophrenia. Also, excessive amount of dopamine in the striatum (cognitive and limbic cortical) can be due to a dysregulation of presynaptic dopamine activity seen in schizophrenia. A result of glutamine study using a proton magnetic resonance spectroscopy revealed high level of glutamine in first episode psychotic and clinically high-risk patients compared to healthy individuals (Larson et al, 2012). Signs and symptoms of Schizophrenia Schizophrenia has both positive and negative symptoms. Positive symptoms are those that indicate either excess or distortion of a person normal functions. For a person to be diagnosis of having schizophrenia, he or she must have two or more positive symptoms based on the DSM-V manual of mental disorder (Larson et al, 2012). Boyd (2015) explained delusions as an erroneous fixed, false beliefs that cannot be transformed by any reasonable argument. Delusions are not easy to change even with a strong evidence contraindicating the belief. The belief of being followed or watched are the most common type of delusion (Larson et al, 2012) Hallucinations are perceptual experiences that take place in the absence of actual external sensory stimuli and may be auditory, visual, tactile, gustatory, or olfactory (Boyd, 2015). 16 PSYCHOSOCIAL ASSESSMENT The key aspect of the disease is disorganized speech or thinking known as “thought disorder” or “loosening of associations.” According to the DSM-V, any disorder in speaking like incoherent speech, loosely associated speech, and tangential worse to markedly affect communication process can be used as an indicator of though disorder (Larson et al, 2012). When there is a difficulty in goal-directed behavior may lead to problems with activities of daily living (ADL). This can also lead to unpredicted agitation or behaviors that are bizarre to others. A decrease in reaction to the immediate surrounding environment are catatonic behaviors that sometimes appears as motionless or bizarre postures (Larson et al, 2012). On the contrary, negative symptoms are behaviors that should be present, but are diminished in schizophrenic patients. It is not as dramatic as positive symptoms; however, they can affect the day to day functioning of the client and are the primary source of long term functional disability. Expressing emotion is difficult for schizophrenic patient because less often they laugh, cry, and get angry. They have flat affect. Avolition may be so profound that simple ADL like dressing or combing of hair, may not get done. Anhedonia prevent patients with schizophrenia not to enjoy activities. They also have problem carrying on a conversation. Negative symptoms cause patients with schizophrenia to withdraw and experience feelings of severe isolation (Boyd, 2015). Gender difference in age at onset of schizophrenia: A meta-analysis. Several studies showed had proven that men develop schizophrenia earlier as compared to women. A total of 46 studies on 29218 males and 19402 females were analyzed to see if there is any gender difference in the onset of schizophrenic patients’ age. Many articles were review including the work of Emil Kraepelin (1909-1915), the first person to suggest that men have an 17 PSYCHOSOCIAL ASSESSMENT early onset of schizophrenia at a younger age than women. The study reviewed studies published between 1987 and 2009, to obtain pooled estimates of gender difference based on the studies, and to ascertain factors that may influence it (Eranti et al, 2013). Eranti and others (2013), age criteria for their study was categorized into; patient’s age at first symptom of schizophrenia, his or her age at first consultation and admission with the disease. DSM-IV was compared to data from develop and developing countries to see if any differences exist. The data were presented and analyzed using a 95% confidence interval through Forest plot and it degrees of freedom equals to 50 (p < 0.001). Based on their results, there is a gender difference in the age at onset of schizophrenia, with males acquiring the disease at an earlier age. Males have an earlier onset by 1.49 years when all the results from the study were tally and analyzed. Age at first symptom of schizophrenia was 1.63 years. The ages for first consultation and admission were 1.22 and 1.07 years respectively. Furthermore, the results show that males may have more worse onset of psychosis, prolonged untreated psychosis as compared to females. Description of Article References Used in this Paper (Annotated Bibliography) Eranti, S. V., MacCabe, J. H., Bundy, H., & Murray, R. M. (2013). Gender difference in age at onset of schizophrenia: A meta-analysis. Psychological Medicine, 43(1), 155-67. doi:http://dx.doi.org.ezproxy.pgcc.edu/10.1017/S003329171200089X This article was selected because it provides information on the onset of schizophrenia in both males and females. Meta-analysis of the article was used to compare men and women and 18 PSYCHOSOCIAL ASSESSMENT factors that affects their onset of schizophrenia making it a very important instrument for healthcare personnel to guide patients and family as when to seek help. The purpose of this article is to explore gender differences in age of onset of schizophrenia. 46 studies in total with 29218 males and 19402 females were analyzed to see if there is any gender difference in age onset of the illness. Study methods were a systematic literature search, meta-analysis and meta-regression, and the study supports that males are diagnosed with schizophrenia at early age than females. Larson, M. K., Walker, E. F., & Compton, M. T. (2012). Early signs, diagnosis and therapeutics of the prodromal phase of schizophrenia and related psychotic disorders. Expert Review of Neurotherapeutics, 10(8), 1347–1359. http://doi.org/10.1586/ern.10.93 This article was selected because it provides a clear description of how neurotransmitters such as dopamine and glutamine affect the brain functions and significantly how neurotransmitters imbalance may lead of schizophrenia. 314 schizophrenic patients were used in the study to compare their body regulation of dopamine and glutamate with 300 healthy people. This study revealed that there is substantial surge in dopamine and glutamate in people affected with schizophrenia. This study helps nurses to understand the pharmacokinetics and pharmacodynamics of most antipsychotics. Al-Asmari, A., & Khan, M. W. (2014). Inflammation and schizophrenia: Alterations in cytokine levels and perturbation in antioxidative defense systems. Human and Experimental 19 PSYCHOSOCIAL ASSESSMENT Toxicology, 33(2), 115-22. doi:http://dx.doi.org.ezproxy.pgcc.edu/10.1177/0960327113493305 This article was selected because it provides one important but less common cause of schizophrenia. The reason for the study was to observe changes in serum oxidative-antioxidative status and cytokine levels of schizophrenic patients. A sum of 91 schizophrenic patients from Saudi Arabia and 50 age- and sex-matched healthy controls were enrolled in this study. The results of the study showed that pro-/anti-inflammatory cytokines and dysregulation of the oxidant–antioxidant balance play important roles in the pathophysiology of schizophrenia. It is an important tool for nurses to educate their patient on some of the causes of schizophrenia. Hüfner, K., Frajo-Apor, B., & Hofer, A. (2015). Neurology issues in schizophrenia. Current Psychiatry Reports, 17(5), 32. doi:10.1007/s11920-015-0570-4 This article was selected because it provides detail explanation of how the brain activities influence schizophrenia. The researcher studied 90 patients with schizophrenia and 85 healthy individuals and compared their brain activities. The results suggested that people with schizophrenia has increased brain neuron activities that accounts for increased psychosis in schizophrenic patients. 20 PSYCHOSOCIAL ASSESSMENT Conclusion and Summary In conclusion, there is a growing evidence base supporting the role of inflammation in the etiology of schizophrenia. The results of the research study provide support to the notion that pro/anti-inflammatory cytokines and dysregulation of the oxidant–antioxidant balance play important roles in the pathophysiology of schizophrenia. Thus, it is suggested that interventions that reduce oxidative stress and augment the antioxidant system may be helpful in the management of schizophrenia patients. However, further research studies are warranted to understand the mechanisms and pathways underlying cytokine imbalance and oxidative stress in schizophrenia (Al-Asmari & Khan, 2014). 21 PSYCHOSOCIAL ASSESSMENT References Al-Asmari, A., & Khan, M. W. (2014). Inflammation and schizophrenia: Alterations in cytokine levels and perturbation in antioxidative defense systems. Human and Experimental Toxicology, 33(2), 115-22. doi:http://dx.doi.org.ezproxy.pgcc.edu/10.1177/0960327113493305 Ackley, B. J., Ladwig, G. B., & Makic, M. B. (2017). Nursing diagnosis handbook: An evidence-based guide to planning care. St. Louis: Elsevier. Boyd, M. (2015). Psychiatric nursing: Contemporary practice (6th ed.). Philadelphia: Wolters Kluwer. Eranti, S. V., MacCabe, J. H., Bundy, H., & Murray, R. M. (2013). Gender difference in age at onset of schizophrenia: A meta-analysis. Psychological Medicine, 43(1), 155-67. doi:http://dx.doi.org.ezproxy.pgcc.edu/10.1017/S003329171200089X Hüfner, K., Frajo-Apor, B., & Hofer, A. (2015). Neurology issues in schizophrenia. Current Psychiatry Reports, 17(5), 32. doi:10.1007/s11920-015-0570-4 22 PSYCHOSOCIAL ASSESSMENT
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