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.
Why is it important for nurses to use a trained interpreter?
To ensure accurate communication and understanding when cultural or language barriers exist.
Using untrained interpreters can lead to misunderstandings and inadequate care.
How can culture impact a client’s view of healthcare?
Culture can shape beliefs about health, illness, and medical practices, influencing how clients perceive their diagnosis and treatment.
This perspective can affect compliance and the client’s overall health outcomes.
Fill in the blank: Nurses should be aware of their own cultural _______ and stigmatizing.
stereotyping
Self-awareness helps in providing culturally competent care.
What is a key practice for nurses when dealing with clients from diverse cultural backgrounds?
Use a trained interpreter when needed.
Effective communication is crucial for patient safety and quality care.
What are the four things psychosocial history assess?
Health and beliefs about illness and wellness, activity/leisure, substance use, stress level and coping abilities
Psychosocial history can provide insight into a client’s mental and emotional well-being.
What is an important question to ask regarding a client’s free time?
How does the client spend free time?
Understanding leisure activities can reveal stressors and coping mechanisms.
What should be evaluated regarding coping strategies?
Usual coping strategies and support systems
Identifying coping strategies helps in understanding how a client manages stress and challenges.
What does orientation refer to in a clinical context?
Recognition of person, place, and time
Sometimes includes a fourth sphere, situation, related to the client’s current circumstances.
What is the documentation format for a person who is oriented to person, place, and time?
Oriented X 3
Disorientation can be noted as ‘oriented X 1’ or ‘oriented X 2’.
What is disorientation?
Absence of correct information about person, place, and time
Disorientation is not synonymous with confusion.
What is the order in which disorientation typically occurs?
Time, place, person
Orientation returns in the reverse order: person, place, time.
How does a confused person differ from a disoriented person?
A confused person cannot make sense of surroundings
They may be fully oriented but still unable to figure things out.
What types of questions does a nurse use to assess memory?
Questions with verifiable answers
Examples include current president, previous president, county of residence.
What is an example of a task to assess a client’s ability to concentrate?
Spell the word ‘world’ backward
Other tasks include serial sevens and repeating days of the week backward.
What should a nurse consider when assessing a client’s intellectual functioning?
Client’s level of formal education
Lack of formal education could hinder performance.
How can a nurse assess a client’s abstract thinking?
By asking them to interpret a common proverb
Correct interpretation indicates intact abstract thinking abilities.
What does the MSE stand for?
Mental Status Examination
Components: LOC, physical appearance, behavior, and cognitive and intellectual abilities
What is the purpose of the MSE?
To evaluate mental health and cognitive status
Allows healthcare professionals to identify abnormalities, diagnose conditions, and monitor progress.
Define ‘Level of Consciousness’ in the context of the MSE.
The patient’s awareness of and responsiveness to their environment.
*not the same thing as orientation as assessed under Sensorium and Intellectual Processes (LOCx4)
List the levels of consciousness assessed in the MSE.
- Alert
- Lethargic
- Stuporous
- Comatose
Not the same thing as the general LOC. This refers specifically to a person’s alertness or responsiveness to their environment.
What does an ‘Alert’ level of consciousness indicate?
Fully awake, aware, and responsive to stimuli.
What is indicated by a ‘Lethargic’ level of consciousness?
Drowsy but can respond appropriately when stimulated.
What does a ‘Stuporous’ level of consciousness require?
Requires vigorous or painful stimuli to elicit a response.
What characterizes a ‘Comatose’ level of consciousness?
Unconscious, unresponsive even to painful stimuli.
Why is the assessment of Physical Appearance important in the MSE?
Changes can indicate underlying psychiatric, neurological, or medical conditions.
What aspects of Physical Appearance should be assessed?
- Hygiene and grooming
- Clothing appropriateness
- General appearance
- Body posture and movement
What behavioral aspects are observed in the MSE?
- Eye contact
- Motor activity
- Attitude toward the examiner
- Mannerisms or gestures
What does the observation of behavior provide clues about?
Emotional state, agitation, or psychomotor changes.
What are the key areas to assess under Cognitive and Intellectual Abilities?
- Orientation
- Memory
- Attention and Concentration
- Abstract Thinking
- Judgment
- Insight
What does ‘Orientation’ assess?
Awareness of person, place, time, and situation.
This falls under cognitive and intellectual abilities in the MSE. Not the same as mental health LOC.
How is ‘Memory’ evaluated in the MSE?
- Immediate: Repeat a sequence of numbers
- Recent: Recall events from earlier in the day
- Remote: Recall past events
What is assessed when evaluating ‘Attention and Concentration’?
The ability to stay focused.
What does ‘Abstract Thinking’ involve in the MSE?
Interpreting proverbs.
What is assessed under ‘Judgment’?
Problem-solving ability and decision-making.
Define ‘Insight’ in the context of the MSE.
Awareness of their condition or need for treatment.
True or False: The MSE is only used for diagnosing psychiatric conditions.
False
What cognitive deficits may indicate conditions like dementia or brain injury?
Deficits in orientation, memory, attention, abstract thinking, judgment, and insight.
What aspects does the nurse assess in the client’s overall appearance?
Dress, hygiene, grooming, posture, eye contact, facial expression, unusual tics or tremors
What are automatisms in the context of client assessment?
Repeated purposeless behaviors indicative of anxiety, such as drumming fingers or tapping the foot
Define psychomotor retardation.
Overall slowed movements
What is meant by waxy flexibility?
Maintenance of posture or position over time even when it is awkward or uncomfortable
What speech characteristics does the nurse assess?
Quantity, quality, abnormalities, relevance to questions, rate, tone, and any difficulties such as stuttering or lisping
Fill in the blank: A client who talks nonstop may be exhibiting _______.
excessive speech
What does it indicate if a client perseverates during conversation?
They seem stuck on one topic and unable to move to another idea
True or False: Neologisms are invented words that have meaning only for the client.
True
What should the nurse document to avoid misinterpretation during client assessment?
Observations and examples of behaviors
What might a minimal ‘yes’ or ‘no’ response indicate during speech assessment?
Lack of elaboration or engagement
Fill in the blank: Waxy flexibility is characterized by the maintenance of _______.
posture or position
The second and third components of MSE, General Appearance and Motor Behavior, covers what six aspects?
- hygiene, grooming
- appropriate dress
- posture
- eye contact
- unusual movements, mannerisms
- speech
What is the difference between mood and affect?
Mood is subjective, while affect is objective.
Mood refers to an individual’s internal emotional state, whereas affect reflects observable emotional expression.
What does ‘blunted’ affect mean?
Showing little emotional response or slow to respond.
Blunted affect indicates a reduced intensity of emotional expression.
Define ‘broad’ affect.
Full range of facial expressions.
Broad affect indicates a normal emotional responsiveness.
What characterizes ‘flat’ affect?
No facial expressions.
Flat affect is often associated with severe mood disorders.
What does ‘inappropriate’ affect refer to?
Affect that is incongruent to mood.
Inappropriate affect may manifest as a mismatch between emotional expression and the context of a situation.
Define ‘restricted’ affect.
Displaying one type of affect, usually serious or somber.
Restricted affect limits the emotional range shown by the individual.
What does ‘labile’ affect refer to?
Unpredictable and rapid mood swings with no apparent stimuli.
Labile affect can fluctuate from depressed and crying to euphoria, often without clear triggers.
What is the term for how the client thinks?
Thought Process
What is the term for what the client says?
Thought Content
What is Circumstantiality in conversation?
Including multiple and unneeded details during a conversation
What is Tangentiality in communication?
Starts talking about trivial information rather than focusing on the main topic
What are Delusions?
Alterations in thoughts that are false fixed beliefs which cannot be corrected by reasoning
Define Associative Looseness.
Unconscious inability to concentrate on a single thought
What is flight of ideas?
When the client’s speech moves rapidly from one thought to another to the point of incoherence
What is Thought Broadcasting?
Believes that their thoughts are heard by others
What does Thought Insertion refer to?
Believes that others’ thoughts are being inserted in their mind
What is Thought Blocking?
Losing one’s train of thought and realizing it
What is Thought Withdrawal?
Believes that their thoughts have been removed from their mind by an outside agency
What is Word Salad?
Words jumbled together with little meaning or significance to the listener
What are Neologisms?
Invented words that have meaning only for the client
What influences client participation in health assessments?
Factors influencing client participation include:
* Client’s health status
* Client’s previous experiences
* Client’s misconceptions about health care
* Client’s ability to understand
* Nurse’s attitude and approach
What is one factor that can affect a client’s understanding during assessments?
Client’s ability to understand
True or False: A client’s previous experiences have no impact on their participation in health assessments.
False
Fill in the blank: The _______ of the nurse can influence client participation in assessments.
attitude and approach
What types of misconceptions might affect a client’s participation in health care?
Client’s misconceptions about health care
How does a client’s health status influence their participation in assessments?
Client’s health status can determine their willingness or ability to engage in the assessment process.
What is the significance of client feedback in health assessments?
Client feedback is crucial for understanding their needs and improving the assessment process.
What are the key characteristics of an ideal environment for conducting assessments?
Comfortable, private, safe, quiet with few distractions
These characteristics help ensure that clients feel secure and can focus on the discussion.
What is a psychosocial interview?
An interview that gathers input from family and friends about their perceptions of the client
This helps to provide a more rounded view of the client’s situation.
What type of questions should be asked to initiate an assessment?
Open-ended questions
These questions allow clients to express themselves freely and provide detailed responses.
When should focused questions be used during an assessment?
When the client cannot organize thoughts or has difficulty answering open-ended questions
Focused questions help guide the conversation and facilitate clearer responses.
What are cognitive interventions aimed at changing?
Cognitive interventions aim to change or reframe an individual’s automatic thought patterns
These thought patterns have developed over time and interfere with the individual’s ability to function optimally. Includes: Priority restructuring, Journal keeping, Assertiveness training, Monitoring thoughts
What is the primary focus of behavior therapy interventions?
Behavior therapy interventions focus on reinforcing or promoting desirable behaviors or altering undesirable ones
This approach seeks to modify behaviors that are not beneficial.
Cognitive interventions aim to change or reframe an individual’s automatic thought patterns that have developed over time and that interfere with the individual’s ability to function optimally. Behavior therapy interventions focus on reinforcing or promoting desirable behaviors or altering undesirable ones: modeling, operant conditioning, systematic desensitization, aversion therapy, meditation|guided imagery|diaphragmatic breathing|muscle relaxation|biofeedback
List some types of relaxation interventions.
- Deep breathing
- Biofeedback
- Hypnosis
These techniques vary in complexity and application. Relaxation interventions range from simple deep breathing to biofeedback to hypnosis. Falls under behavioral therapy.
In assessing QUALITY of speech, what three categories are considered?
Speed, Volume and Tone.
Categories such as Pattern and Nature reflect an assessment of speech CONTENT, not quality.
