Chapter 8: Assessment Flashcards
What does assessment involve?
Collection, organization, and analysis of information about client’s health
What is assessment often referred to?
Psychosocial Assessment, which includes mental status examination
Purpose of psychosocial assessment?
Construct a picture of clients current emotional state, mental capacity, and behavioral function
Client’s Health Status: The informaiton that the nuse obtains may reflect what?
Client’s pain or anxiety rather than assessment of the clients situation. REcognize these situation and deal with them before continuing assessment
Client’s Previous Experiences / Misconceptions about Health Care: What may cause the client to have difficulty answering questions directly?
If client is reluctant to seek treatment or has previous unsatisfactory experiences with the health care system . May minimize or maximize symptoms or problems
Nurses Attitude and Approach: If client feels questions to be short or rush, what may happen?
May provide only superficial information or omit discussing problems in some areas together
Environment: Where should a psychosocial assessment be conducted?
An environment that is comfortable, privaee, and safe for both client and nurse
Environment: Where should you never perform an assessment?
An isolated location , particularly if the client is unknown
How to Phrase Questions: How should an assessment be started?
With open-ended questions
How to Phrase Questions: Examples of open-ended questions to begin assessment?
What brings you here today?
Tell me what has been happening to you
How can we help you?
How to Phrase Questions: How do questions need to be?
Clear, simple, and focused on one specific behavior or symptom
How to Phrase Questions: What are some examples of focused or closed-ended questions?
How many hours did you sleep last night?
Have you been thinking about suicide?
How well have you been sleeping?
How to Phrase Questions: what tone should nurse use?
Nonjudgmental tone and language, particularly when asking about sensitive information
How to Phrase Questions: How would you phrase a question toward a client in regards to their parenting role?
“What types of discipline do you use” rather than “how often do you physically punish your child”
How to Phrase Questions: When beginning an assessment, nurse must address
the client’s feelings and perceptions to establish a trustiing working relationship before proceeding with the assessment
Content of the Assessment: What is the framework that we should use?
History
General Appearance/Motor Behavior
Mood and Affect
Thought Process and Content
Sensorium and Intellectual Processes
Judgement and Insight
Self-Concecpt
Roles and Relationships
Physiologic and Self-Care Concerns
Content of the Assessment: What components fall under history?
Age, developmental stage, cultural considerations, spirtiual beliefs, previous history
Content of the Assessment: What components fall under general assessment and m otor behavior?
Hygiene and grooming, appropriate dress, posture, eye contact, unusual movement, speech
Content of the Assessment: What compoennts fall under mood and affect?
Expressed emotions, facial expressions
Content of the Assessment: What components fall under thought process and content?
Content (what clients thinking), process (how client is thinking), clarity of ideas, self-harm or suicide urges
Content of the Assessment: What falls under sensorium and intellectual processes?
Orientation, confusion, memory
Content of the Assessment: What falls under abnormal sensory experiences or misperceptions
concentration and abstract thinking abilitites
Content of the Assessment: What falls under judgement and insight?
Judgement (interpretation of environment, decision-making ability, insight (understanding one’s own part in current sitation)
Content of the Assessment: What falls under self-concept ?
Personal view of self, description of physical self, personal qualities or attributes
Content of the Assessment: What falls under roles and relationships?
Current roles, satisfaction with roles , success at roles, significant relationships, support systems
Content of the Assessment: What falls under physiologic and self-care considerations?
Eating habits, sleep patterns, health problems
History: Background assesments include
clients history, age, and developmental stage, cultural and spiritual beliefs, and beliefs about health and illness
History: What insight may a family provide about a patients past?
Has client experienced similar diffilties in the past? Has client been admitted into hospital?
History: What does western culture except of poeple when they reach adulthood?
They will become financially independent, leave home, and make their own life decisions
History: What doesEastern culture expect of people when they reach adulthood?
In some households, three generations may live in a household and elders of family make decisions for all.
History: To avoid making inaccurate assumptions about one cultures, what should a nurse ask?
Nurse must ask clients about the beliefs or health practices that are important to them or how they view themselves in context of socieety
General Appearance and Motor Behavior: What does the nurse assess here?
The client’s overall appearance including dress, hygiene and grooming. Are they appropriately dress for their age and weather? Is client unkempt or disheveled?
General Appearance and Motor Behavior: What are some specific terms used in making assessments of general appearance and motor behavior?
Automatisms, Psychomotor Retardation, Waxy Flexibility
General Appearance and Motor Behavior: What are Automatisms?
Repeated, purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair or tapping food
General Appearance and Motor Behavior: What is Psychomotor Retardation?
Overall slowed movements
General Appearance and Motor Behavior: What is waxy flexibility?
Manintenance of posture or position over time even when it is awkward or uncomfortable
General Appearance and Motor Behavior: Another thing they look for are neologisms. What is this?
Invented words that have meaning only for the client.
Mood and Affect: Mood refers to what?
Clients pervasive and enduring emotional state. Client may make statements about feelings like “Im depressed”
Mood and Affect: What does Affect mean?
Outward expression of the client’s emotional state. Client may infere clients mood from postures , gestures, or ton e
Mood and Affect: Common terms used in assessing affect include?
Blunted Affect Broad Affect Flat Affect Inappropriate Affect Restricted Affect
Mood and Affect: What is Blunted Affect?
Showing little or a slow-to-repsond facial expression
Mood and Affect: What is Broad Affect?
Displaying a full range of emotional expressions
Mood and Affect: What is Flat Affect?
Showing no facial expression
Mood and Affect: What is Inappropriate Affect?
Displaying a facial expression that is incongruent with modo or situation, often silly or giddy regardless of circumstances
Mood and Affect: What is restricted affect?
Displaying one tpye of expression ,usually serious or somber
Mood and Affect: What is labile called?
When the client exhibits unpredictable and rapid mood swings from depressed and crying to euphoria with no apparent stimuli
Thought Process and Content: What is Thought Process?
Refers to how the client thinks. Can infer clients thought process from speech and speech patterns
Thought Process and Content: What is Thought Content?
Is what the client actually says.
Thought Process and Content: What are some common terms related here?
Circumstantial Thinking Delusion Flight of Ideas Ideas of Reference Loose Associations Tangential Thinking Thought Blockng Thought Broadcasting Thought Insertion Thought Withdrawal Word Salad
Thought Process and Content: What is Circumstantial Thinking?
Client evantually answers a question but only after giving excessive unneccesary detail
Thought Process and Content: What is Delusion?
Fixed false belief not based in reality
Thought Process and Content: What is Flight of Ideas?
Excessive amount and rate of speech composed of fragmented or unrealted ideas
Thought Process and Content: What is ideas of reference?
Clients inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news
Thought Process and Content: What are loose associations?
Disorganized thinking that jumps from one idea to another with little or no evident relation
Thought Process and Content: What is tangential thinking?
wandeirng off topic and never providing the information requested
Thought Process and Content: What is thought blocking?
stopping abruptly in the middle of a sentence or train of thought
Thought Process and Content: what is thought broadcasting?
delusional belief that others can hear or know what client is thinking
Thought Process and Content: What is thought insertion?
delusional belief that others are putting ideas or thoughts into clients head
Thought Process and Content: What is thought iwthdrawal?
delusioal belief that others are taking the clients thoughts away
Thought Process and Content: What is word salad?
Flow of unconnected words that convey no meaning to the listener
Assessment of Suicide or Harm Toward Others: How does the nurse ask the patient if he has plans of suicide?
Must ask them directly.
Assessment of Suicide or Harm Toward Others: Ideation Suicide example
are you thinking about killing yourself
Assessment of Suicide or Harm Toward Others: plan suicide example
do you have a plan to kill yourself
Assessment of Suicide or Harm Toward Others: method suicide example
how do you plan to kill yourself
Assessment of Suicide or Harm Toward Others: access suicide exampleh
how would you carry out this plan. Do you have access to the measn to carry out this plan
Assessment of Suicide or Harm Toward Others: where suicide example
where would you kill uyourself
Assessment of Suicide or Harm Toward Others: when suicide example
when do you plan to kill yourslef
Assessment of Suicide or Harm Toward Others: timing suicide example
what day or time of day o you plan to kill yourself
Assessment of Suicide or Harm Toward Others: What should nurse do when client makes specific threats?
Legally obligated to warn the person who is the target of the threats or plan
Orientation: What is this?
Refers to the client’s recognition of place, person, time
Orientation: What is the order of which a person becomes disoriented?
First loses track of time
Then Place
Then PErson
Orientation: How does orientation return to a person?
First person, then place, and finally tim e
Orientation: Different between disorientation and confusion?
Confused person cannot make sense of his or her surroundings or figure things out
Memory: How can a nurse verify memory?
By not asking if theyhave memory issues, but ask them to specifially recall something
Memory: Some questions to assess memory?
What is the name of the current president?
Who was the president before that?
Ability to Concentrate: How does the nurse assess this ability?
Ask client to spell world backword.
Serial Sevens
Repeat days of the weak backward
Abstract Thinking and Intellectual Abilities: Nurses asseses ability for abstract thinking. What is this?
Making associations or interpretations about a siutation or comment. Can do this by asking client to interpret “a stitch in time says nine”
Abstract Thinking and Intellectual Abilities: What is concrete thinking?
When a client continually gives literal translations
Abstract Thinking and Intellectual Abilities: Example of Abstract vs Concrete thinking?
People who live in glass houses shouldn’t throw stones
Abstract: Don’t critize others for things you may be guilty of doing
Literal: If you throw a stone at a glass house, the glass will break
Sensory-Perceptual Alterations: What are Hallucinations?
False sensory perceptions or perceptual experiences that do not really exist. Involve the five senses.
Sensory-Perceptual Alterations: Most common Hallucination?
Auditory hallucination
Judgement and Insight: What is judgement?
Refers to the ability to interpret one’s environment and siutation correctly and to adapt one’s behavior and decisoins accordingly
Judgement and Insight: What is insight?
Ability to understand the true nature of one’s siutation and accept some personal responsibility for that siutation
Judgement and Insight: Nurse can frequently infer from insight form client’s ability to
realistically describe the strengths and weaknesses of his or her behavior
Judgement and Insight: Example of poor insight?
Client who places all blame on others for his own behavior saying “It’s my wifes fault hat I drink and get into fightS:
Judgement and Insight: Another example of pooor insight?
Expects all problems to be solves with little or no personal effort
Self-Concept: What is this?
The way one views oneself in terms of personal worth and dignity.
Self-Concept: How do you assess this?
Nurse can ask client to describe him or herself , what characteristic they like, or what theyd change
Roles and Relationships: Types of role may vary but they usually include
family, occupation, and hobbies or activites
Roles and Relationships: Family roles include
son/daughter, sibiling, parents, children
Roles and Relationships: questions to ask client?
Do you feel close to your family?
Do you hve/want relationship with SO
Can you meet your sexual needs satisfactiorily?
Roles and Relationships: Due to social media, it is important to do what?
Distinguihs between face-to-face contact with others versus online contact. May not actually be friends with those people
Data Analysis: This involves thinking about
the overall assessment rather than focusing on isolated bits of information . Looks for patterns or themes
Data Analysis: TRaditionally , data anlysis leads to the formulation
of nursing diagnoses as a basis for hte client’s plan of care
Psychological Tests: Two basic types of tests are
inteligence tests and personality tests
Psychological Tests: Intelligence tests are designed to evaluate
the clients cognitive abilitites and intellectual functioning
Psychological Tests: Personality tests reflect
the clietns personality in areas such as self-concept, impulse control, reality testing, and major defenses
Psychological Tests: Personality tests may be objective meaning
constructed of true-or-false or multiple coice questions
Psychological Tests: Other personality tests are called projective tests. What are these?
unstructured and are suually conducted by the interview method
Psychological Tests: Stimuli for projective tests are
pictures or rorschachs inkblots but may respond with answers that vary widely
Psychological Tests: Both intelligence tests and personality tests are frequently critized as being
culturally biased. Important to consider client’s culture and environment
Psychiatric Diagnoses: What is the DSM-5?
Medical didagnsoes of psychiatric illness are found here. Universally used in diagnoses of illness
Mental Status Examination: What does an exam for ones cognitive ability include?
Orientation to person, time, place, date, season and day of week
Ability to interpret proverbs
Ability to perform math calculations
Ability to write
Components of a through pschosocial assessment include
clients history, general appearance and motor behavior , mood and affect, thought process and content, sensorium and intellectual process, judgement and insight, self-concept , roles and relationships, and physiologic and self-care considerations
What important factors in client can influence the psychosocial assessment?
Ability to participate and give feedback
Physical health status
emotional well-being adn perception of situation
ability to comunicate
