Chapter 9Assessment of Psychiatric–Mental Health Clients 1

The first step in the nursing process, the assessment of the client, is crucial. Assess the client in a holistic way, integrating any relevant information about the client’s life, behavior, and feelings. Remember that the focus of care, beginning with the initial assessment, is toward the client’s optimum level of health and independence from the hospital. Schultz and Videbeck, 2009

Learning Objectives After studying this chapter, you should be able to Discuss the nursing process Articulate the purpose of a comprehensive nursing assessment Differentiate the purpose of a focused and a screening assessment Understand the significance of cultural competence during the assessment process 3

Learning Objectives (cont.) Recognize how disturbances in communication exhibited by a client can impair the assessment process Describe the importance of differentiating among the six types of delusions during the assessment process Distinguish the five types of hallucinations identified in psychiatric disorders 4

Learning Objectives (cont.) Illustrate the differences between obsessions and compulsions Discriminate levels of orientation and consciousness during the assessment process Reflect on how information obtained during the assessment process is transmitted to members of the health care team Formulate the criteria for documentation of assessment data 5

Six Steps of the Nursing Process Assessment Nursing diagnosis Outcome identification Planning (formulation of a plan of nursing care) Implementation of nursing actions or interventions Evaluation of the client’s response to interventions 6

The assessment phase of the nursing process includes nurse–client interaction during the collection of data about a person, family, or group by the methods of observing, examining, and interviewing. 7

Client Assessment Types of Assessment Types of Data Comprehensive assessments Focused assessments Screening assessments Types of Data Objective data Subjective data 8

Cultural Competence During Assessment (Mackey-Padilla, 2005; Kanigel, 1999) Assess and clarify the client’s cultural values, beliefs, and norms. Assess the client’s degree of cultural assimilation/acculturation. Assess the client’s perspective regarding feelings and symptoms. Elicit the client’s expectations and ask what is important for the health care provider to know. Learn how to work with interpreters. When using an interpreter, talk to the client rather than the interpreter. Seek collaboration with bilingual community resources. 9

Collection of Data Memory Appearance Affect or emotional state Behavior, attitude, and coping patterns Communication and social skills Content of thought Orientation Memory Intellectual ability Insight regarding illness Spirituality Sexuality Neurovegetative changes 10

Impaired Communication Blocking Circumstantiality Clang association Echolalia Flight of ideas Looseness of association Mutism Neologism Perseveration Tangentiality Verbigeration Word salad 11

Content of Thought Delusions Hallucinations Depersonalization Obsessions Compulsions 12

Sleep Pattern Asking clients about their sleep patterns and any problems is an often neglected, but extremely important, area to investigate. Insomnia Acute or primary insomnia Secondary insomnia 13

Medical Issues Pain Physiological responses to medication 14

Supporters or Caregivers Assessment Informal supporters or caregivers are prone to depression, anxiety, grief, fatigue, changes in social relationships, or other issues. Strain related to care provision may affect employment, financial, physical, social, and time domains. 15

Documentation of Assessment Data Objective Descriptive Complete Legible Dated Logical Signed 16

Key Terms Delusions Acute insomnia Depersonalization Affect Echolalia Flight of ideas Hallucinations Illusion Acute insomnia Affect Blocking Circumstantiality Clang association Compulsions 17

Key Terms Insight Insomnia Looseness of association Memory Mutism Neologism Neurovegetative changes Nursing process Obsessions Perseveration Secondary insomnia Tangentiality Verbigeration Word salad 18

Reflection Complete an assessment of a client in your clinical practice setting. What information did you obtain? How was that information crucial to the client’s care? ?