Assessjment-Ch 8-T1 Flashcards
Psychosocial Assessment
Purpose
Picture of patient’s current emotional state, mental capacity, behavioral function.
Basis for developing plan of care.
Clinical baseline to evaluate effectiveness of treatment or measure patient’s progress.
Factors Influencing psychosocial Assessment
Patient participation/feedback.
Client’s health status.
Client’s previous experiences/misconceptions about health care.
Client’s ability to understand.
Nurse’s attitude, approach.
Interview Questions
Open-ended to initiate assessment.
Focused if patient unable to organize thoughts or has difficulty answering open-ended questions.
Assessment Content: History
Age Developmental stage Cultural considerations Spiritual beliefs Previous history
Waxy flexibility
maintenance of a posture/position over time even when it is awkward or uncomfortable.
Automatisms
repeated purposeless behaviors often indicative of anxiety (drumming fingers, twisting hair, foot tapping).
Psychomotor retardation
overall slowed movements.
neologisms
invented words that have meaning only for the client.
Labile
Rapidly changing mood, unpredictable.
Affect
the outward expression of the emotional state
Blunted (facial expression)
showing little or slow-to-respond facial expression
Broad (facial expression)
displaying full range of expression.
Flat (facial expression)
showing no facial expression
Inappropriate (facial expression)
displaying a facial expression that is incongruent with mood or situation (silly, giddy).
Restricted (facial expression)
displaying one type of expression (serious, somber).
Thought process/content:
Content (what the client ____) and process (how client ___).
says
thinks
Circumstantial thinking
answers question only after giving excessive unnecessary detail
Delusion
a fixed false belief not based in reality.
Flight of ideas
excessive amount & rate of speech composed of fragmented or unrelated ideas.
Ideas of reference
inaccurate interpretation that general events are personally directed toward them.
Loose associations
disorganized thinking that jumps from one idea to another with little relation between thoughts.
Tangential thinking
wandering off topic & never providing the information requested.
Thought broadcasting
belief others know what the client is thinking
insertion
belief others are putting thoughts into client’s head
blocking (in referance to thought process)
stopping abruptly
withdrawal (in reference to thought process)
others are taking thought away
Word salad
flow of unconnected words that convey no meaning
Orientation/confusion
person, place, time, situation.
Memory
recent/remote.
Concentration
ask client to do tasks – spell word backwards.
Abstract thinking abilities
interpret a common proverb – literal interpretations are evidence of concrete thinking.
Judgment
interpretation of environment
Insight
understanding one’s own part in current situation
Self-concept:
Personal view of self.
Description of physical self.
Personal qualities or attributes.
Roles/relationships
Current roles.
Satisfaction with roles.
Success at roles.
Significant relationships.
Support systems (see Box 8.3, p.145).
Physiologic and self-care considerations
Eating habits.
Sleep patterns.
Health problems.
Compliance with prescribed medications.
Ability to perform activities of daily living.
Overall assessment data
Not isolated bits of information
Patterns or themes in data → nursing diagnoses
Psychological tests
IQ & personality tests
Psychiatric diagnoses
DSM-5
Mental status exam (MSE
focuses on cognitive abilities
Intelligence tests:
Cognitive abilities
Intellectual functioning
Personality tests:
Reflect the client’s personality in areas such as
self-concept,
impulse control,
reality testing,
major defense mechanisms.
Diagnostic and Statistical Manual of Mental Disorders (DSM
The DSM classifies psychiatric disorders into categories.
The DSM describes each disorder and provides the diagnostic criteria for each disorder.
cognitive abilities
Orientation to person, time, place, date, season, day of the week.
Interpretation of proverbs.
Math calculations.
Memorization, short-term recall.
Identification of common objects.
Ability to follow multistep commands.
Ability to write or copy a simple drawing
