Videbeck Ch 8, Assessment Flashcards
What is the first step in the care of the client?
Assessment, or collecting data or information.
This is crucial for understanding the client’s needs.
What does the nurse do after collecting data?
Organizes and analyzes the data to identify needs and/or problems and establishes priorities for the client’s care.
This step is essential for effective care planning.
In psychiatric-mental health nursing, what is data collection often referred to as?
Psychosocial assessment.
This includes a mental status examination.
What is the purpose of the psychosocial assessment?
To construct a picture of the client’s current emotional state, mental capacity, and behavioral function.
This helps in understanding the client’s overall well-being.
What are cues in the context of assessment?
Data that require action.
Identifying cues is crucial for timely interventions.
What is another role of the assessment in client care?
It serves as a clinical baseline to evaluate the effectiveness of treatment and actions or to measure the client’s progress.
This aids in adjusting care plans as necessary.
Psychosocial assessment pieces together the Mental Status of a client (emotions, feelings, behaviors and functions)
Psychosocial assessment
What are the components of a psychosocial assessment?
History, General Assessment and Motor Behavior, Mood and Affect, Thought Process and Content, Sensorium and Intellectual Processes, Abnormal Sensory Experiences or Misperceptions, Judgment and Insight, Self-Concept, Roles and Relationships, Physiological and Self-Care Considerations
What factors should be included in the history component of a psychosocial assessment?
- Age
- Developmental stage
- Cultural considerations
- Spiritual beliefs
- Previous history
Name the aspects to assess in General Assessment and Motor Behavior for psychosocial assessment?
- Hygiene and grooming
- Appropriate dress
- Posture
- Eye contact
- Unusual movements or mannerisms
- Speech
What should be observed in Mood and Affect during a psychosocial assessment?
- Expressed emotions
- Facial expressions
In the Thought Process and Content component of a psychosocial assessment, what does it entail?
Content (What client is thinking), process (how client is thinking), clarity of ideas, self harm or suicide urges
In the Thought Process and Content component, what does ‘process’ refer to?
How client is thinking
What does the Sensorium and Intellectual Processes component assess?
- Orientation
- Confusion
- Memory (recent and remote)
- Ability to concentrate
- Abstract thinking and Intellectual Abilities
What is assessed under Abnormal Sensory Experiences or Misperceptions?
Concentration and abstract thinking abilities
What does Judgment and Insight evaluate in a psychosocial assessment?
- Judgment (interpretation of environment)
- Decision-making ability
- Insight (understanding one’s own part in the current situation)
What factors contribute to Self-Concept in a psychosocial assessment?
- Personal view of self
- Description of physical self
- Personal qualities or attributes
What should be evaluated regarding Roles and Relationships?
- Current roles
- Satisfaction with roles
- Success at roles
- Significant relationships
- Support systems
What physiological and self-care considerations are important in a psychosocial assessment?
- Eating habits
- Sleep patterns
- Health problems
- Compliance with prescribed medications
- Ability to perform the activities of daily living
True or False: The component ‘Self-Concept’ includes the client’s personal qualities or attributes.
True
Fill in the blank: The assessment of __________ evaluates the client’s expressed emotions and facial expressions.
Mood and Affect
Psychosocial assessment components
What should nurses be aware of regarding clients’ cultural beliefs?
Nurses should be aware of culture-specific foods, specific beliefs toward healthcare, and how the client’s diagnosis is viewed in their culture.
Understanding these aspects can improve communication and care.