Assessment of Thought Process and Content (Nursing)

by Brenda Marshall, EdD, MSN, RN

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    00:01 Oftentimes, we are asked about thought process.

    00:06 How are we going to know a person's thought process? Well, in some situations, we can actually observe a person's thought process.

    00:18 I have clients who now walk around with a hand sanitizer on their person because it allows them to give into their obsessions and wash their hands frequently during the day with their germaphobia and they do it with handwashing - not with handwashing, they do it with their hand sanitizers.

    00:44 We also can be listening to their speech.

    00:48 When we're listening to them, are they speaking in a logical manner or are they illogical? Are their ways of speaking coherent? Is what they are saying coherent or is incoherent? Is it a jumble of words that don't make any sense at all? Also, are they answering the question with a goal intention? Do we see that they are able to start in the beginning of a story, make their way through the middle of a story, and go to the end of the story, or are they being tangential? Which means that they start in one place and then they have a thought that takes them in another direction, and then another tangent takes over and they go into a different direction? How about loose associations? Loose association is when they start speaking and a word comes up and they then start talking about that word.

    01:51 So, they're talking to you about one thing or another.

    01:55 They're telling you about having had coffee for breakfast this morning.

    02:01 And then, they say, "Yes, I had coffee this morning, and it was coffee with milk.

    02:09 Do you like brown dresses?" Because in their mind, coffee with milk reminded them of the color brown and now they've thought brown and they go to brown dresses.

    02:22 When that happens and I'm interviewing a patient, I might say to them, "Wow, I notice you were talking about coffee, and we've just jumped to brown dresses.

    02:33 Can you tell me how you got there?" It's a very - it gives us a little bit of insight into the way their thought process is going.

    02:43 Is their thought process evasive? Are they not being able to actually address the situation and their thoughts are kind of shifting away from whatever it is that you are looking to have a conversation on? Perhaps, their thoughts are racing. They are going so fast and they are moving so quickly.

    03:08 Oftentimes, a patient might say to you, "I can't sleep at night. I have racing thoughts.

    03:15 There are so many thoughts that are going through my mind that it keeps me up." A lot of people who suffer from anxiety will also say, "These racing thoughts, they just keep coming about what might be and what if and what if this happens? And I cannot stop them." That's what lets us know that these are racing and also intrusive.

    03:43 How about thoughts that are blocked? When a person is not able to get beyond a thought and their thoughts are literally in their mind blocked from coming forward.

    03:57 Another thing that we see when we're considering about thought processes is the person who suddenly starts making up words.

    04:05 That's called neologisms that comes from the latin, neo, meaning new, logisms, the words, new words, that have no meaning in our dictionary.

    04:18 And so, these are words that suddenly pop up in a conversation, but you need to be asking clarifying questions to say, "What exactly does that mean?" And to find out why this person is now making up words.

    04:37 How is their thought process going that is leading them to that kind of neologism? We can find out about a person's content of their thoughts not just by observing, but also asking. So, if we hear a person who is talking to us and saying, "I am the president of the United States," and we know that that is a delusionary thought, it has no basis in fact or reality, it's time for us to ask a clarifying question.

    05:34 "Do you think that you are the current president of the United States?" And listen to the answer. Or if we are looking at a person and we see that they are looking around the room in such a way that we understand their thoughts are that they are not safe and perhaps they are being watched, we can stop and say, "Excuse me, I'm noticing the way you're looking around the room.

    06:11 I'd like to ask you a question. Do you think that you are being watched?" We then need to be listening to what their answer is because otherwise, we won't know their thought.

    06:25 We need to not assume that we know it, but we need to be able to step on the next step, which is asking the clarifying question, and then asking, "Do you think you're being watched? Do you believe that you are the current president of the United States?" And if they give us an answer that we are not clear on, we ask them to please explain what they mean.

    06:55 Can you please explain to me what you mean by that? I'm sorry, I am not understanding.

    07:02 We're never going to say to someone, "You are not making sense." We are going to say, "I am not understanding." We want to give the patient the opportunity to clarify and explain what they mean.

    07:16 If we see them suddenly going [sniffing sounds], "Eww," or [scratching noises], we might start thinking this person is having a hallucination.

    07:36 They might be having olfactory, they might be smelling something that we're not smelling, or they might be hearing voices.

    07:44 They might be feeling tactile sensations or seeing something.

    07:49 It's important for us to be clear. "Excuse me, do you hear other voices than mine?" Or "Are you smelling something at this time? Can you describe it to me?" "I noticed that you're scratching on your arm. Are you having some sensations?" This is really helpful, especially if you want to ask them if they're hearing voices.

    08:16 And that is because there is something called command voices and it's imperative that we know if they are hearing voices, are they hearing voices that are telling them to do something? We need to know what that voice is saying.

    08:33 So, "Do you hear other voices besides mine?" And if the client or patient says, "Yes, I do," you want to say, "Please tell me what that voice is saying." If the voice is saying to injure somebody or injure you, safety, safety, safety.

    08:53 Make sure you have a clear distance and that you have capacity to get help.

    08:59 So, what do we mean when we say delusions? Well, generally, it means that there is a very, very strong belief in something that has no basis in reality that even when we give factual and reality-based information, that person is incapable of accepting what we're saying as the truth, and they hold onto their belief. That is a delusion.

    09:29 There are different kinds of delusions that a person might have.

    09:34 The first one that I'm going to talk about is paranoid delusions.

    09:39 Paranoid delusions is when a person believes that someone's out to get them.

    09:44 That there may be one person, there may be a government, there may be a group of people, and that delusion overtakes their thought process, and most everything they do from that point on, once they believe that delusion, is going to be to try and protect themselves from the oncoming attack they believe is going to happen. You might hear patients say, "The government has put sensors in my head, and I need to get the sensors out because they know what I'm thinking because they're going to come for me." You cannot tell a person who is having paranoid delusions that they are false.

    10:34 They will just believe that you are part of the enemy.

    10:37 These delusions need to be medically treated.

    10:43 Medications need to be taken and we need to keep that person safe.

    10:50 Another delusion a person might have is grandiosity.

    10:54 Grandiose delusions is when a person believes, for example, they are the queen of England or they are the president of the United States, and that they deserve to be treated differently from all other people because they are so important, and they are so great.

    11:12 The other is somatic delusions. Body concerns.

    11:17 A person who is of normal height, weight, believing that they are enormously fat.

    11:23 Someone who is healthy believing they have cancerous lungs and that they are going to die.

    11:34 I have had patients who have believed they're pregnant.

    11:38 Again, you can't stop the delusion. You have to treat the delusion.

    11:43 It is a symptom of a mental illness. We also have people who have erotic delusions.

    11:52 Again, these delusions, this eroticism is part of a symptom.

    12:00 We're not going to be able to convince them nor should we try.

    12:07 We need to document it and make sure we start treating it.

    12:13 For me, the most dangerous delusion is that nihilistic delusion.

    12:20 That believing that nothing really matters, and everything can be destroyed.

    12:25 We want to make sure that we keep a close eye on patients who have nihilistic delusions because those patients can become dangerous because they can act on their delusions.

    12:38 A person can also have a delusion of being guilty.

    12:42 I had a patient who had been in psychiatric care from the time he was 17.

    12:48 When I met him, he was 29.

    12:51 He said he needed to go into Narcotics Anonymous and Alcohol Anonymous.

    12:57 And when I asked him why, he said, "Because I am drink - I am guilty of drinking and using drugs." And the psychiatrist said to him, "You know, you live on a psychiatric unit. It is a closed unit.

    13:11 You have been living there since you're 17.

    13:14 Why do you think that you have an alcohol and drug addiction?" And he said, "I don't think I have it, I know that I'm using drugs.

    13:26 I'm guilty of it and I apologize and if you let me come into your program, I promise I'll never miss any meetings." How is a delusion different from an illusion? Well, delusions are disturbances in the way we think.

    13:46 We start believing a belief system that has no reality, no basis in reality.

    13:53 Illusions are perceptual disturbances.

    13:57 For example, the patient who has an IV tube and sees the tubing and thinks that it might be a worm. Well, the tubing is actually there.

    14:09 The tubing is based in reality but the person's perception of what that tubing is, is incorrect.

    14:18 Another perceptual disturbance that does not have any basis in reality are those hallucinations.

    14:25 These are false sensory perceptions. We have to ask the patient.

    14:31 If you see a patient responding bizarrely to an IV tubing, you have to say, "What exactly are you seeing?" If you see a person who is responding to - and we call it internal stimuli because it's not in the environment, those are hallucinations.

    14:53 You have to say, "Can you tell me what you are feeling or seeing or smelling?" It's important to know that perceptual disturbances can affect any one of our five senses.

    15:05 So, we're talking about olfactory, tactile, visual, gustatory, and auditory.

    15:12 There are times when you may have a patient who goes to taste something and suddenly says, "Oh, my gosh, this is poison. I taste the poison in this." And that interferes with their ability to take their meds, to take - get adequate nutrition, so we look at these things and we understand that it - any one of our five senses can be affected by a perceptual disturbance.

    About the Lecture

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

    Included Quiz Questions

    1. Incoherent
    2. Obsessive
    3. Evasive
    4. Goal-directed
    1. Loose associations
    2. Tangential speech
    3. Thought blocking
    4. Delusions
    1. Evasive
    2. Flight of ideas
    3. Thought blocked
    4. Loosely associated
    1. “I’m sorry, that word isn’t familiar to me, can you tell me what it means?”
    2. “Please use a different word that you did not make up, so I can understand you.”
    3. “What you’re doing is called a neologism, and it’s a symptom of your mental illness.”
    4. "So, what I’m hearing is that you’re upset with what happened in group. Is that right?"
    1. “Do you think you’re the Queen of England?”
    2. “It seems unlikely that you’re the Queen of England, right?"
    3. “Do you have a history of delusions?”
    4. “If you’re the Queen of England, what are you doing here?"
    1. “Are the voices telling you to do something?”
    2. “How long have you been hearing voices?”
    3. “What do the voices sound like?”
    4. “Does taking the medication stop the voices?”
    1. Somatic
    2. Nihilistic
    3. Paranoid
    4. Grandiose

    Author of lecture Assessment of Thought Process and Content (Nursing)

     Brenda Marshall, EdD, MSN, RN

    Brenda Marshall, EdD, MSN, RN

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