Assessment and Mental Status Examination

• Chapter 8 covers assessment

Psychosocial Assessment

• Data collection is a key aspect
• The purpose is to get a picture of the client's current emotional state including their mental capacity and behavioral function
• A plan of care can be developed
• Provides a clinical baseline to evaluate the effectiveness of treatment or chart the client's progress

Factors Influencing Assessment

• Client participation and feedback
• Client's health status including physical and mental components
• Client's previous experiences and any misconceptions about health care
• Client's ability to understand information
• The nurse's attitude and approach impacts the quality of the assessment

Interview Environment

• A comfortable, private, and safe environment is essential
• Quiet setting with few distractions
• Input from family and friends can provide information about their perceptions
• The information from family and friends may be limited due to certain factors

Interview Questions

• Open-ended questions are best to start
• Focused questions are better if the client cannot organize thoughts

Assessment of History

• Age and developmental stage
• Cultural considerations and spiritual beliefs
• Previous and family history
• Beliefs about health and illness

Assessment of Appearance and Motor Behavior

• Note hygiene/grooming and appropriateness of dress
• Assess posture and eye contact
• Note any unusual movements or mannerisms like automatisms, psychomotor retardation, or waxy flexibility
• Speech patterns including nonstop talking, perseveration, minimal responses, or irrelevance needs assessment
• Note any neologisms (newly made up words) in speech

Mood and Affect Assessment

• Mood refers to the emotional state, e.g., happy, sad
• Affect is the outward expression of the emotional state
• Assess for consistency between stated mood and observed affect
• Common terms for affect include blunt, broad, flat, inappropriate and restricted

Thought Process and Content

• Process covers how the client thinks
• Content covers what the client says
• Circumstantial thinking means providing unnecessary details, but eventually reaching the point
• Tangential thinking means moving from thought to thought that relate in some way but never get to the point
• Delusion is a fixed, false belief not based in reality
• Ideas of reference involves thinking insignificant events relate directly to them
• Flight of ideas involves rapid jumps between somehow related topics
• Loose Associations involves jumps between unrelated topics
• Thought broadcasting, insertion, blocking or withdrawal
• Word salad is a flow of unconnected words that conveys no meaning

Suicide and Harm Assessment

• Assess suicide or harm toward others
• Ask the client directly about thoughts of suicide
• Ask about anger, hostility, or threats toward another person
• Investigate specific threats or plans to harm someone
• Duty to warn applies when there is a target of threats

Suicide Assessment Questions

• Ideation: "Are you thinking about killing yourself?"
• Plan: "Do you have a plan to kill yourself?"
• Method: "How do you plan to kill yourself?"
• Access: "How would you carry out this plan? Do you have access to the means to carry it out?"
• Where: "Where would you kill yourself?"
• When: "When do you plan to kill yourself?"
• Timing: “What day or time of day do you plan to kill yourself?"

Sensorium and Intellectual Processes

• Orientation to time, place and person
• Memory: recent and remote
• Ability to concentrate, like spelling "world" backward or subtracting 7 serially from 100
• Evaluate abstract thinking and intellectual abilities

Abstract vs. Concrete Thinking

• Proverb: A stitch in time saves nine
• Abstract: Fixing something now avoids bigger problems later
• Literal: Don't forget to sew up holes in your clothes
• Proverb: People who live in glass houses shouldn't throw stones
• Abstract: Don't criticize others for things you also do
• Literal: If you throw a stone at a glass house, the glass will break

Sensory-Perceptual and Judgement

• Sensory perceptual alterations like hallucinations
• Auditory ones are most common, followed by visual
• Judgment is the ability to interpret environment
• Insight is the ability to understand true nature of one's situation

Self Concept, Roles and Relationships

• The way one views oneself in terms of personal worth and dignity
• Assess by asking physical characteristics/body image
• Note emotions the client experiences frequently
• Current roles and ability to fulfill them
• Satisfaction with relationships
• Online activity/social media
• Categories of family assessment

Categories of Family Assessment

• Parenting practices like discipline, supervision, and rules
• Social interaction among family members
• Patterns of problem-solving and decision-making
• Finances, transport, and child care
• Relationships with extended family
• Health behaviors, including mental or physical illness

Physiological and Self Care

• Eating and sleeping habits
• Chronic health problems
• Use of drugs and/or alcohol
• Noncompliance with prescribed medications

Data Analysis

• Assessment should not be isolated
• Patterns in data lead to conclusions about client's strengths, needs, problems, and risks
• It is an ongoing and dynamic process

Mental Status Examination

• Cognitive abilities
• Orientation to person, time, place, date, season, day of the week, interpretation of proverbs, math calculations etc.
• Memorization and short-term recall
• Ability to follow multistep commands
• Ability to write or copy a simple drawing

Self-Awareness Issues

• Gathering all necessary information is needed, without judgment
• Ask about personal topics with openness and clarity
• Examine own beliefs to gain self awareness
• Do not allow beliefs to interfere with the nurse-client relationship

Questions about the primary purpose, accuracy, environment, and appropriate use of focused questions during a psychosocial assessment interview. Includes questions about automatism, blunted affect, waxy flexibility, and neologisms in relation to a client's general appearance, motor behavior, and speech.