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Ch_ 8 MH-Assessment

Psychiatric-Mental Health Nursing

The purpose of the psychosocial assessment Is to construct a picture of the client's current emotional state, mental capacity, and behavioral function.
What is the first step of the:Psychosocial assessment which includes the mental status examination Assessment: Involves the collection, organization, and analysis of information about the clients health.
Factors influencing assessment. 1. Client participant/Feedback 2. Client's health Status 3. Client's previous experiences/misconceptions about health care. 4. Client's ability to understand/ 5. Nurse's attitude and approach
Client participation/Feedback influences psychosocial assessment how? If the client is unable or unwilling to participate, some area of the assessment will be incomplete or vague. Example: The client who is extremely depressed may not have the energy to answer questions or complete the assessment.
Client's health status influences psychosocial assessment how? If the client is anxious, tired, or in pain, the nurse mah have difficulty eleciting the client's full participation, the client may need to rest, receive medications to alleviate pain, or be calmed before the assessment can be continued.
Client's previous experience/misconceptions about health care, influences psychosocial assessment how? Perception of his/her circumstances can elicit emotions that interfere with assess-ment. If reluctant to seek treatment or had previous unsatisfactory experiences may have difficulty answering questions directly. minimize/maximize symptoms, not give infor
Client's ability to understand, influences psychosocial assessment how?, If hearing is impaired or language differs from that of the nurse, the client may misunderstand of misinterpret what is being asked.
Nurse's attitude and approach, influences psychosocial assessment how? If perceives questions to be short/curt,or feels rushed/pressured may provide only superficial infor, omit discussing problems such as child abuse, domestic violence if nurse seems uncomfortable, nonaccepting Nurse response/approach must be matter-of-fac
How to conduct the psychosocial assessment interview should: 1. Environment 2. Input from family and friends 3. How to phrase questions
Environment- related to the interview should: In a comfortable, private, place safe for both client/nurse, fairly quiet with few distractions. A conference room ensures no one will overhear but it should not be an isolated location to ensure safety of self and client another person may be present.
Input from family and friends related to the interview should: If accompanied obtain their perceptions of clients behavior/emotional state, if the client gives permission it is desirable to conduct separate interviews may limit the amount and type of infor obtained such as cases of abuse or intimidation.
How to phrase questions related to the interview should: Using open-ended questions allows client to begin as he/she feels comfortable and gives the perception of clients situation. If client cannot organize thoughts or has difficulty answering open-ended questions ask direct clear, simple/focused questions
Examples of open-ended question: 1. What brings you here today? 2. Tell me what has been happening to you. 3. How can we help you?
Examples of focused or closed-ended questions: 1. How many hours did you sleep last night? 2. Have you been thinking about suicide? 3. How much alcohol have you been drinking? 4. How well have you been sleeping? 5. How many meals a day do you eat? 6. What over-the-counter medications are you taki
The nurse should use nonjudgmental tone and language, particularly when asking? Sensitive information such as drug or alcohol use, sexual behavior, abuse or violence, and childrearing practices.
Using non-judgmental language and matter-of-fact tone avoids: Giving the client cues to become defensive or to not tell the truth. When asking about parenting role ask "What type of discipline do you use? rather than "How often do you physically punish your child?" the 1st question is more likely to elicit the truth
Content of the psychosocial assessment contains which components: 1. History 2. General appearance and motor behavior 3. Mood and affect 4. Thought process and content 5. Sensorium and intellectual processes 6. Judgment and insight 7. Self-concept 8. Roles and relationships 9. Physiologic and self-care concerns
Psychosocial assessment component: History 1. Age 2. Developmental stage 3. Culture considerations 4. Spiritual beliefs 5. Previous history
Psychosocial assessment component: General assessment and motor behavior 1. Hygiene and grooming 2. Appropriate dress 3. Posture 4. Eye contact 5. Unusual movements or mannerism 6. Speech
Psychosocial assessment component: Mood and affect 1. Expressed emotions 2. Facial expressions
Psychosocial assessment component: Thought process and content 1. Content (what client is thinking) 2. Process (how client is thinking) 3. Clarity of ideas 4. Self-harm or suicide urges
Psychosocial assessment component: Sensorium and intellectual processes 1. Orientation 2. Confusion 3. Memory
Psychosocial assessment component: Abnormal sensory experiences or misperceptions 1. Concentration 2. Abstract thinking abilities
Psychosocial assessment component: Judgment and insight 1. Judgment (Interpretation of environment) 2. Decision-making ability 3. Insight (understanding one's won part in current situation)
Psychosocial assessment component: Self-concept 1. Personal view of self 2. Description of physical self 3. Personal qualities or attributes
Psychosocial assessment component: Roles and relationships 1. Current roles 2. Satisfaction with roles 3. Success at roles 4. Significant relationships 5. Support systems
Psychosocial assessment component: Physiologic and self-care considerations 1. Eating habits 2. Sleeping patterns 3. Health problems 4. Compliance with prescribed medications 5. Ability to perform activities of daily living.
Specific terms used in making assessments of general appearance and motor behavior include: 1. Automatisms; repeated purposeless behaviors often signs of anxiety, drumming fingers, twisting locks of hair, tapping foot. 2. Psychomotor retardation; overall slowed movements 3. Waxy flexibility; awkward or uncomfortable maintenance of posture
Neologisms Invented words that have meaning only for the client
Mood refers to: The client's pervasive and enduring emotional state.
Affect refers to: Is the outward expression of the client's emotional state.
Created by: valorea