Assessment of Insight and Attention (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:01 We're also going to be assessing a person's insight.

    00:05 We want to make sure that we are seeing whether or not this patient has insight into their own problems.

    00:14 And the way we assess that is we ask questions.

    00:18 We say to them, "So, what do you think is causing your problem?" Or "What brought you in today?" Or "Could you possibly describe to me the situation that you find yourself in?" And we listen. We don't pass judgement. We just listen.

    00:37 And if the - when we say, "Why do you think you're in the hospital?" And they say, "I have no idea. My family thought it would be good for me.

    00:46 Besides, I've been working too hard, and this is kind of a vacation." They're demonstrating that they're lacking insight.

    00:55 We document that there is a lack of insight.

    00:58 If, in fact, we say, "What do you think is causing your problems?" And they say, "My drinking has gotten out of control and now I'm drinking in the morning, I drink before I go to work, I'm really having brain fog, I'm having a hard time getting up in the morning to even go to work." They're showing us they have insight into the problem that's brought them into the hospital.

    01:23 And when we know that they have insight, we know that they're going to be a good collaborator to try and identify what we can do to help them to recover.

    01:36 We also want to know if they are aware of what role they had in their current situation.

    01:46 This is difficult. It's hard enough without mental illness to understand the role that we play in our own situation.

    01:56 I often tell people that every single decision and choice that you have made to - up and including today, has brought about the life that you are experiencing today.

    02:10 A person with mental illness oftentimes does not see themselves as having a role in how they are feeling their life to be.

    02:23 Oftentimes, they feel as though they had been victimized.

    02:26 Many times, even as adults, we watch as we say, "Well, what role do you think you played in the situation you're in?" You were picked up by the police, you had gotten into a fight, what was your role in that? And they will say, "I had no role in that. I was a bystander, and then all of a sudden, fists started to fly, and the next thing that I knew, I was being brought in, and being told that there was something wrong with me." We want people to start taking responsibility for their actions.

    03:01 We want people to see how they are responsible in some ways.

    03:07 We want to be able to separate the illness from the behavior where we can so that we can start moving them towards a behavior that helps them start feeling some self-efficacy or belief in themselves that they can accomplish their own goals.

    03:29 And so, in order to do that, we have to find out how did they get some help for the problem that they have? That person said, "Oh, my drinking is my problem and I'm having a hard time waking up in the morning and I have to have a drink at lunch, or I start having very bad headaches." We might say, "Oh, that's very interesting.

    03:52 So, how do you get help for that?" And maybe they say, "I don't get help. I just take a couple of Tylenol and I just push through until I can get my evening drink." Or they might say, "Well, I used to go to AA." What does this give us if they can tell us how they get help for a problem? It tells us how they might be able to get help in the future.

    04:18 What has worked for them in the past? That's going to give us some information to help them what might help them in the future.

    04:29 Also, during the psychiatric evaluation, we are going to be assessing the person's attention.

    04:36 Now, during the mental health evaluation, as we're doing a mental status exam, we have a number of different things that we do as part of the mental status exam.

    04:51 For example, we might be giving them a span of numbers and have them repeat them forwards and then backwards.

    04:59 So, we might say, "Here are some numbers: 2, 4, 5, and 7," and ask them to repeat it. 2, 4, 5, and 7.

    05:10 Then, we might say, "Can you say those numbers backwards?" 7, 5, 4, 2.

    05:19 We also might ask some to spell a word forwards and backwards.

    05:25 Now, a person's inability to spell the word forwards and backwards might be related to their language skills, their educational skills.

    05:35 There are a number of different strategies that we have to be thinking about.

    05:41 If English is a second or maybe third language for someone, asking them to spell the word welcome forwards and backwards is actually giving them a task that would be too difficult and would not actually be assessing their attention.

    05:57 So, knowing your patient as you're doing the mental status exam is really helpful.

    06:03 Also, the attention while you're giving the span of numbers to the patient, if your patient has a learning disability and they have a problem with numbers, you might - if they're not able to give you the numbers 2, 4, 5, and 7, and then 7, 5, 4, and 2, you might be able to say, "Have you had any difficulties in the past with remembering numbers?" Also, calculations. We're going to be asking them to do some calculations so we might ask them to subtract the same number in a sequence.

    06:39 For example, "Can you start at 100 and take 5 away and count backwards from 100 at 5?" So, it'd be 100, 95, 90, 85, 80, and see if they are able to do those simple calculations.

    06:58 You want to do the same thing for addition.

    07:01 "Can you do addition counting up from 10 to 100 and adding 5?" So, it'd be 10, 15, 20, 25, 30, 35, 40, up to 100.

    07:16 One of the things we often do is to ask them to calculate change of a dollar.

    07:23 "If I give you a dollar and I'm buying something for 78 cents, how much money will you give back to me?" I'll tell you right now that many of our younger clients have some difficulty in calculating change, even in addition, because they become very dependent on their phones and their calculators.

    07:50 Even if they're working in a grocery store, they don't have to calculate change anymore.

    07:56 They just simply put it into the register and the register will tell them exactly how much money is required to give back.

    08:05 This way, you are just getting an overview on this person's capacity for calculations and for being able to do some numeric examples.

    About the Lecture

    The lecture Assessment of Insight and Attention (Nursing) by Brenda Marshall, EdD, MSN, RN is from the course Psychiatric Assessment (Nursing).

    Included Quiz Questions

    1. “What brought you in today?”
    2. “What do you think is causing this concern?”
    3. “Can you describe to me the situation that you find yourself in?”
    4. “You know you have schizophrenia, right?”
    5. “Don’t you think that sounds pretty unlikely?”
    1. “I know that my mood is low because I stopped taking my antidepressants. I’m in the hospital so I can get back on them and feel better again.”
    2. “Sometimes I feel like there’s bugs crawling on me even though I know it’s not real. I don’t like my medication, but I know I need to take it to make the feeling go away.”
    3. “I’m in the hospital because my family doctor diagnosed me wrong. They think I have bipolar disorder, but I really just have a thyroid problem.”
    4. “Everyone is making such a fuss about me. I’m just a little bit stressed. All I need is a day or two to sleep in the hospital, and I’ll feel better in no time.”
    5. “Doctors love prescribing therapy and medication, but I don’t believe in it. All I need is to start drinking more water and I’ll be back to my old self.”
    1. Have the client repeat a string of numbers forwards and backwards
    2. Have the client spell a word backwards and forwards
    3. Have the client calculate change for a dollar
    4. Have the client count backwards from 100 by fives
    5. Have the client read a passage from a book and recall it five minutes later
    1. Having the client spell the word 'hospital' backwards
    2. Having the client repeat the numbers three, five, and six forwards
    3. Having the client count backwards from 100 by sevens
    4. Having the client repeat the numbers six, eight and nine backwards

    Author of lecture Assessment of Insight and Attention (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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