Chapter 10: The Assessment Process Flashcards
Assessment as a process
The nursing process is a systematic and dynamic approach to collecting and analyzing client information and is the first step in the provision of nursing care. The four essential components are assessment, planning, implementation and evaluation.
An assessment is a purposeful systematic and dynamic process in nurses relationships with individuals in their care. It involves the collective, validation, analysis, synthesis, organization as documentation of client health illness information
Assessment is an ongoing, purposeful, systematic and dynamic process. The Canadian Federation of mental health nurses steps for affective assessment. One collaborate with clients and team members to get holistic information through observation engagement examination and interview. Two assess documents and information to identify health status potential for wellness healthcare defects and risk potential. 3 Formulate and document a plan of care with client and family and team 4 Refine and expand client assessment information, documents significant changes in status, compare new data with baseline 5 Assess and anticipate potential needs and risks 6 Determine the most appropriate an available therapeutic modality that meets the clients needs
Types of assessment
Two types comprehensive or focussed
A comprehensive settlement includes a complete health history and physical examination. Considers the psychological, emotional, social, spiritual, ethnic and cultural dimensions of health. The purpose is to develop a holistic understanding of the individuals problems and games as well as their strengths and resources. Due to the broad scope it may take days or weeks to complete.
I focussed assessment is the collection of specific information about a specific need, problem or situation and may involve evaluation of such things as medication effects, risk for self harm and suicide, knowledge defects or the adequacy of supports and resources. These are BRIEFR and narrow in scope and more present oriented. Maybe used to screen people at high risk for For a particular problems or disorders and they might use the mini mental status exam for the Hamilton rating scale for depression.
Type of assessment depends on two factors the immediate needs of the client in the practice setting. During a psychiatric emergency you don’t have time to perform a comprehensive assessment. Instead of focussed assessment will provide the treatment team with sufficient info to address the clients symptoms. The mandate of a psychiatric and mental health facility or program determines the type of services it offers which intern dictates the nature of the assessment. During the first admissions to a psychiatric unit an individual is likely to undergo a comprehensive assessment. Nurses working in telehealth or a mobile mental health crisis team will collect only the information required to address the immediate problem
Assessment techniques observation
Nonverbal cues also communicate important information. Nurses must use all five senses and integrate assessment into older encounters with client. Attention to nuances of dress, behavior, facial expression, gesture and interaction with others, especially when the individual is not aware of being observed. For example the nurse observes hygiene and grooming but also whether the clients dress is appropriate to the season and situation. Observations include behavioural evidence of perceptual disturbances or disorder thoughts such as listening or talking to unseen others and apparent inconsistencies between reports and a nurses observations.
Assessment techniques examination
A health assessment includes health history, physical examination and diagnostic testing. Individuals who live with serious mental illnesses are at greater risk for developing a range of chronic physical conditions and have a shorter life expectancy. This can be due to the illness Or a consequence of treatment. Other risk factors for physical illness include smoking, alcohol and drug use, obesity, poverty and self-care defects. Medical conditions can mask imitate or worsen psychiatric symptoms.
The mental status exam is one type a focussed assessment used to systematically assess an individual psychological, emotional, social and neurologic functioning. The findings are highly subjective and rely on the clinicians knowledge community communication skills interpretation and judgement
Assessment techniques interview
An interview is a semi structured conversation and at building rapport, obtaining facts, clarifying perceptions and meanings, validating observations and comparing understandings. Must be warm and respectful and approach clients as collaborators. Competent interviewers engage in empathetic listening which is being sensitive to the changing meaning the person is feeling in temporarily living in the others life without making judgments. Nurses may also interview family and friends However limits to collection and disclosure of personal information must respect privacy rights.
Effective interviewing negotiate the terms of the interview with all participants, has a private comfortable setting free from interruption, has a realistic time management, has an interview were attentive to the nonverbal communication, avoids jargon, begins with a less sensitive topic and moves towards sensitive issues as report develops, leaves time at the end for closure and future planning
Barriers to effective interviewing include lack of clarity about the purpose and parameters of the interview, asking too many closed and questions, avoiding silence, asking complex questions, making assumptions, avoiding or ignoring expressions of emotion
Assessment techniques Collaboration
The WHO identified the following benefits of interprofessional practice. Reduced length of hospital stay, improved quality of life for patients and families, improved access to care, enhanced patient safety and improved recruitment and retention of healthcare professionals. This results in better health, improved access to services, more efficient use of services and higher levels of satisfaction for both consumers and health professionals. PMH teams include clients and their families, nurses, physicians, psychologist, social workers, pharmacist, occupational therapists and recreational therapists.
Types and sources of information
Client information falls into two categories objective and subjective. Objective data, signs, are directly observable and measurable. The physical examination, vital signs and diagnostic tests all-year-old objective data. Subjective data, symptoms, or neither directly observable nor measurable. It is what the client and others report about their observations, beliefs, emotions, perceptions, experiences and motivations. Subjective information Gives an idea of a patient’s life experiences, personal history and developmental stage past learning ethnicity and culture. Both objective and subjective data is generated from primary or secondary sources. Individual clients are the primary source of information and secondary data comes from family and other healthcare providers written reports and client records
Documentation
Healthcare records are legal documents. The type of information collected and how it’s documented or regulated by the program or facility which has policies and procedures to comply with provincial and territory legislation. Two approaches to documentation source oriented and problem oriented. Source oriented document documentation each discipline is assigned a section of the clients records such as nurses notes or physicians notes. This tends to fragment the data which is antithetical to holistic care. Problem Oriented documentation, everyone involved with the Care makes entries in the same section of the record. But it facilitates interpersonal collaboration and keeps team members oriented towards clients goals and needs.
Information entered through fillable forms, flowsheets, checklists and narrative notes. Electronica health records are more common practitioners use SOAP subjective data objective data assessment and plan implementation, DAR data action plan or PIE problem implementation and evaluation, methods to organize their notes. Charting by exception documents only health illness responses that deviate from well articulated standards.
Biologic domain
Health history
Health history establishes a subjective database about the clients current and past past health illness experiences, identify strengths and resources, suggests actual and potential health problems and defects it is an opportunity to build rapport.
Physical examination
Process by which a clinician collects objective information about the clients health. Includes anthropomorphic measurements such as height and weight, vital signs, and examination of all body systems, and diagnostic testing appropriate to age risk level and sex. Physical examination aids in diagnosing disease or illness and establishes a baseline for evaluating change. Particular Attention is paid to abnormalities of hepatic, renal or urinary function since these metabolize or excrete psychiatric medications. White blood cell counts and electrolyte levels are also noted
Psychological domain responses to mental health problems
PMH disorders are clinically significant patterns of behaviour or emotion that are associated with some level of distress, suffering or impairment in one or more areas such as school, work, social and family interactions or the ability to live independently. Current thinking is that mental health illness exists on a continuum. One in five responders around the world met criteria for mental disorder in the previous year and 29% experienced a common mental disorder at some point during their lives. It’s important to explore the individuals experience of the illness and identify the person strategy for managing the illness and the effectiveness of those strategies. Many have specific fears about losing jobs their families or about the personal safety
Psychological domain mental status examination
Mental status exam
Is a systematic assessment of an individual’s appearance, affect, behaviour and cognitive process. It provides a snapshot of the person subjective report and experiences and the examiners observations and impressions at the time of the interview this performed by health practitioners across several disciplines and clinical settings to evaluate developmental, neurologic, and psychiatric disorders
General observances
Appearance. Describe appearance, dress, hygiene, odors, pupil size, tattoos and piercings, skin tone such as duskiness paler or flushing, nutritional status and energy levels. Psycho motor behaviour like Tivitt he. Observe posture, gait, motor coordination, facial expression, mannerism, gesture and activity. Attitude towards interviewer. The attitude might be described as accommodating, cooperative, open, friendly, apathetic, bored, guarded, suspicious, hostile or evasive.
Mood and affect
Mood refers to pervasive and sustained emotion and it is what the person reports about his or her prevailing emotional state. Tends to be stable overtime. Terms to describe mood include Euthymic is normal, euphoric is elated and dysphoric is depressed disquieted and restless. Refers to immediately expressed perfect emotion that is referred by the examiner from facialist questions, vocalizations and behavior. It is described in terms of its range, intensity, appropriateness and stability. Effective range can be full or restricted such as someone talking about the death of a loved one in a monotone voice. Stability of affect can be described As mobile which is normal or labile (Displaying a wide range of strong emotions in a relatively short period of time).
Speech
Speech is described in terms of its quality, rate and fluency of production and quantity. For quantity an individual may be described as talkative, for both or expensive we’re having posse or poverty of speech. Rate of speech maybe slow, hesitant, fast or preserved. Fluency refers to the apparent ease at which speech is produced. Pressured speech is speech that is rapid Increased in amount and difficult to understand it is associated with mania. A phasic disturbances are problems of speech output and maybe cognitive or emotional and origin. Quality refers to characteristics such as monotone, whispered, slurred, mumbled, loud. Interview were also notes in Piedmont such a stuttering response latency the time it takes for an individual to respond, repetition rhyming or unusual worries
Perception
Perception is the complex series of mental events involved with talking in a sensory information from the environment and the processing of that information into mental representations. To perceptual disturbances associated with mental illness or hallucinations and illusions. Hallucinations are false sensory perceptions not associated with external stimuli and are not shared by others. Hallucinations may be experienced in any of the five major sensory modalities auditory (most common), visual, tactile, olfactory or gustatory. Solutions or a miss perception or miss representation of real sensory stimuli. Example miss identifying the wind as a voice Colleen ones name we’re thinking that a label on a piece of clothing is an insect
Thought
Indirectly assessed through language in terms of its content in process. Thought content refers to the subject matter occupying a persons thoughts. Thought process is the matter in which thoughts are formed and expressed.
Sensorium
Assess his brain function and cognitive abilities.
Level of consciousness. This assesses arousal or wakefulness terms include alert, awake, lethargic, somnolent, comatose, stuporous.
Orientation. Is a Cognitive function involving awareness of the dimensions of time, person and place. The examiner determine orientation by asking questions about time place and person because impairments tend to exist in this order.
Memory. Divided into four spheres immediate retention and recall , recent memory, short-term memory, remote or long-term memory.
Attention and concentration. Normally tested by getting patient to count backwards from 100 by increments of seven
Insight and judgement
Involve the ability to examine ideas, conceptualize facts, social problems and think abstractly. Insight describes a persons understanding of a set of circumstances. Reflects awareness of their own thoughts and feelings and the ability to compare them with thoughts and feelings of others. Judgement is the ability to reach a logical decision about a situation and to choose a reasonable course of action after examining and analyzing various possibilities.
Psychological domain stress and coping patterns
Identification of major stressors in an individual’s life helps the nurse to develop and support the use of successful coping behaviours in the future. Identify current stressors and coping strategies and evaluate effectiveness.
Psychological domain assessing risk and protective factors
Assessment takes into account both the presents and balance of respecters, protective factors and promoted factors. Risk factors are characteristics, conditions, situations and events that increase the individuals vulnerability to threats to safety or well-being. Risks include safety, PMH disorders and risks for increasing or exacerbating symptoms. Protective factors are attributes or conditions of an individual, family and/or community when present produces, mitigates or eliminates risk. Promoted factors or conditions or attributes of individuals, Family and or communities that actively enhance well-being. Protective and promote factors increase the possibility of positive adaptive and healthy outcomes.
Suicide or self harm
Suicide is an intentional, self-inflicted act that results in death. Self harm well purposeful is often repetitive behaviour that involves infliction of harm to one’s body without suicidal intent and is often used as a method to relieve psychological distress. Suicide risk assessment involves getting details regarding. Suicide ideation which is fought about deliberate self harm her self inflicted death. Threats of suicide verbal or behavioral indication that an individual is planning to end their life. Suicide attempt action taken with the attentive and in one’s life. Self harm thoughts or deliberate self injury us behavior not intended to end one’s life. To get this info nurse asked specific questions such as do you have the things you need to carry out this plan. Have you made preparations for your death by writing a goodbye note giving away possessions.
Assaultive or homicidal Ideation
Evaluation of the level of threat and individual poses to others. Delusions or hallucinations that involve harming or killing others are of particular importance. Questions to ask include do you intend to harm someone if yes whom. Do you have a plan for how we might do this if yes what are the details of the plan.
Social domain assessing gender identity
Much social information is elicited during the health history in the MSE and includes individual information such as current living situation, individuals family origin, existence and quality of significant relationships. Also assess his work, education and social and leisure activities.
Assessing gender identity
Sex refers to the biologic and physiologic features associated with being male, female or intersex. Gender denotes socially constructed characteristics. Gender identity is one’s self identification along a male female and or man woman continuum regardless of the composition of the physical body. Sexual orientation is a persons sexual and emotional attraction to another person and the behaviour or social affiliation that may result from this attraction. Sis gender indicate someone who sense of personal identity and gender aligns with that assigned at birth. Transsexual, transgender is nonconforming gender questioning and non-binary gender are general terms referring to people whose gender identity does not match the sex they were signed up earth. Gender norms and rules can influence a persons vulnerability to various health conditions and disease and physical and mental health over the lifespan.
Social domain functional status
Functional status
Understanding how an individual functions in his or her day-to-day life is a vital part of assessment. Crosscutting symptom measure can be used at the initial interview and overtime to follow changes in status and treatment response. World health organization disability assessment schedule 2.0 A self administered tool is recommended for assessing the difficulties experienced over the past 30 days due to health. Six domains including understanding and communication, Moving and getting around, hygiene dressing eating and staying alone, interacting with other people, domestic responsibilities, leisure work and school, and joining in community activities.
Ethnic and cultural assessment
Ethnicity and culture affect a persons worldview and frame the persons belief about life and death health and it’ll nice and roles and relationships. The nurse should ask questions such as do you think of yourself as belonging to a particular ethnic or cultural group. Which parts of your culture most important to you. To who do you turn when you feel physically or mentally ill. The DSM5 offers a cultural formation interview do used to obtain this information
