Mental Health Assessment Skills - Chapter 9

Mental Health Treatment Plan

• Physical and psychological problems are interconnected; each impacts the other.
• Comprehensive assessment is required for individuals entering mental health care.
• Treatment plans guide client care, monitor progress, and facilitate communication.

DSM-5 Diagnosis

• DSM-5 (Diagnostic and Statistical Manual of Mental Disorders) is a key tool for diagnosis and clinical practice.

Collaborative Treatment Planning

• Agreement on treatment goals between the client and care team is crucial for planning.
• Combines medical treatments with psychotherapies and behavioral therapies tailored to individuals.

Nursing (Therapeutic) Process

• Framework for goal-directed care that emphasizes client involvement and partnership.
• Steps involve Assessment, Diagnosis, Planning, Intervention, and Evaluation.

Assessment Process

• Involves gathering, verifying, and communicating client information.
• Holistic assessment includes physical, intellectual, social, cultural, and spiritual dimensions.
• Objective data can be obtained through exams and observations; subjective data encompasses clients' emotions and mental states.

Data Collection Methods

• Interviews, observational techniques, physical assessments, and rating scales are key methods.

Psychiatric Assessment Focus

• Emphasizes problems, coping behaviors, and client resources.
• Risk assessment for potential self-harm or violence is essential.

Effective Interview Guidelines

• Objectivity and appropriate responses are critical for successful interviews.
• Caregivers must avoid assumptions, respect cultural values, and monitor personal biases.

Psychosocial History Assessment

• Evaluates health perceptions, leisure activities, substance use, stress, and coping mechanisms.
• Identifies cultural beliefs that may influence care.

Mental Status Exam Components

• Assesses physical appearance, behavior, cognitive abilities, consciousness levels, and language capabilities.
• Evaluates orientation to time, person, and place; memory; judgment; and abstract thinking.

Mini Mental State Exam

• Tests orientation, attention span, memory (registration and recall), and language skills.

Health History and Physical Assessment

• Aims to identify physical conditions that may affect behavior.
• Includes a review of general health, past illnesses, hospitalizations, and family health history.
• Assesses the function of body systems and daily living activities.