Chapter 8 Assessment Flashcards
Psychosocial Assessment
Picture of a client’s current emotional state, mental capacity, behavioral function
Basis for developing plan of care
Clinical baseline to evaluate effectiveness of treatment or measure progress
Factors Influencing Assessment
Client participation /feedback
Client’s health status
Client’s previous experiences
Client’s misconceptions about health care
Client’s ability to understand
Nurse’s attitude and approach: This will affect the interaction
Psychosocial Interview
Environment
* Comfortable, private, safe
* Quiet w/ few distractions
Input from family, friends
* Information about their perceptions of client
* Information may be limited by certain factors
Questions
* Open-ended to initiate assessment
* Focused if client cannot organize thoughts or has
difficulty answering open-ended questions
Mental Status Exam
Primarily Observational
- Except for mood, thought content
Appearance
Attitude
Behavior
Mood
Affect
Cognition
Speech
Thought Process
Thought Content
Perception
Insight & Judgment
Mini Mental Status Exam: Primarily used for those w/ dementia
Appearance/Motor Behavior
Eye contact
Unusual movements, mannerisms
Speech & speech pattern
Hygiene, grooming
Appropriate dressing
Posture
Mood
Subjective
Affect
Objective
Facial expressions: Expressive-flat
Thought Process/Content
Process - how the client thinks
Content - what the client says
Circumstantial: Adds additional info before getting to the answer
Tangential: Being sidetracked, info does not apply to the current topic
Delusions: False fixed belief, nothing is going to change it
Flight of ideas: Random bursts of thoughts & ideas that do not fully complete themselves
Loose associations: Not making sense
Thought broadcasting: The belief that others can hear what you’re thinking
Thought insertion: The belief that someone/ something is putting ideas in my head
Thought blocking: No recollection or pregnant pause
Thought withdrawal: Belief that thoughts are being taken away
Word salad: A bunch of words do not make sense together in a sentence
Suicide or Harm to Others
Ask client directly:
Ideation, plan
- Know when the plan is going to occur
Anger, hostility toward another person
Specific threats or plans to harm someone
Duty to warn
- Stay w/the patient or get someone to stay w/them while getting help
Sensorium/ Intellectual Process
ORIENTATION
MEMORY
ABILITY TO CONCENTRATE
ABSTRACT THINKING
INTELLECTUAL ABILITIES
ABNORMAL SENSORY EXPERIENCES
SENSORY MISPERCEPTIONS
Judgement
Ability to interpret the environment & ability to make appropriate decisions
Insight
Ability to understand true nature of one’s situation
Components of Self-Concept
Personal worth and dignity
Description of physical characteristics
Body image
Emotions frequently experienced
Physiological & Self-Care Considerations
Eating habits
- Ask for BM: psychiatric meds can cause constipation
Sleep patterns
Major or chronic health problems
Use of drugs and/or alcohol
Noncompliance w/ prescribed medication
Roles & Relationships
Current roles
Ability to fulfill roles
Changes in roles
Satisfaction with relationships
Online activity / social media
