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
Spiritual Needs
Meaning & purpose in life
Faith or trust in someone or something beyond ourselves
Hope
Love
Forgiveness
Data Analysis
Patterns or themes
Conclusions about strengths, needs
Nursing diagnoses
Ongoing, dynamic process
Psychological tests
Psychiatric diagnoses
Mental status examination
Intelligence Tests
Personality Tests
Self-Awareness Issues
Gather all information
needed.
* Judgments are not part of
assessment process.
1
Be open, clear, direct
when asking about
personal or
uncomfortable topics.
2
Examine own beliefs;
gain self-awareness
(growth-producing
experience)
3
Do not allow personal
beliefs to interfere
with nurse–client
relationship and
assessment process.
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