Chapter_09.pptx

Mental Health Assessment Skills Chapter 9 Copyright © 2023 by Elsevier, Inc. All rights reserved. 1  Mental Health Treatment Plan  Every psychological problem has physical effects, and each physical illness has psychological effects  Individuals e...

Mental Health Assessment Skills Chapter 9 Copyright © 2023 by Elsevier, Inc. All rights reserved. 1  Mental Health Treatment Plan  Every psychological problem has physical effects, and each physical illness has psychological effects  Individuals entering into the mental health care system undergo a comprehensive assessment Copyright © 2023 by Elsevier, Inc. All rights reserved. 2  Mental Health Treatment Plan (cont)  Purposes of the mental health treatment plan  Acts as a guide for planning and implementing client care  Serves as a vehicle for monitoring the client’s progress and the effectiveness of therapeutic interventions  Serves as a means for communicating and coordinating client care Copyright © 2023 by Elsevier, Inc. All rights reserved. 3  DSM-5 Diagnosis  The Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition (DSM-5) is a tool that is used to facilitate diagnosis and guide clinical practice Copyright © 2023 by Elsevier, Inc. All rights reserved. 4  Mental Health Treatment Plan (cont)  When the team and the client agree on the treatment goals, a course of action is planned  Medical treatments (medications) are combined with psychotherapies, behavioral therapies, and other therapeutic actions  Treatment plans are developed specifically for the individual client Copyright © 2023 by Elsevier, Inc. All rights reserved. 5  Nursing (Therapeutic) Process  Designed to support goal-directed care for clients  Serves as an organizational framework for effective care  Encourages us to focus on the client and develop appropriate and effective care measures Copyright © 2023 by Elsevier, Inc. All rights reserved. 6  Nursing (Therapeutic) Process (cont)  Clients are involved as partners in care  Caregivers help clients problem-solve by involving them in the care planning process  The art of choosing the best course of action must be practiced carefully Copyright © 2023 by Elsevier, Inc. All rights reserved. 7  Nursing (Therapeutic) Process (cont)  Assessment  Diagnosis  Planning Copyright © 2023 by Elsevier, Inc. All rights reserved. 8  Nursing (Therapeutic) Process (cont)  Intervention  Evaluation Copyright © 2023 by Elsevier, Inc. All rights reserved. 9  Assessment Process  Includes “gathering, verifying and communicating of information relative to the client”  Holistic assessment includes gathering information regarding physical, intellectual, social, cultural, and spiritual aspects of each client  Objective data can be measured and shared  For mental health clients – obtained through physical exams, daily assessments, diagnostic test result, repeated observations of behaviors  Subjective data relates to clients’ perceptions  Information is abstract, difficult to measure or share. For MH clients, emotions and mental states are subjective, difficult to measure Copyright © 2023 by Elsevier, Inc. All rights reserved. 10  Data Collection Methods  Data collection methods for care providers include the following:  Interview  Observational techniques  Physical assessment  Rating scales and inventories Copyright © 2023 by Elsevier, Inc. All rights reserved. 11  Assessment Process  The psychiatric assessment tool focuses on obtaining data about the problems, coping behaviors, and resources of clients  Risk factor assessment  Required for clients who may pose a risk for violence toward themselves or others Copyright © 2023 by Elsevier, Inc. All rights reserved. 12  Data Collection  Effective interviews  Success of any client interview rests on the caregiver’s ability to listen objectively and respond appropriately  Guidelines for an effective interview include: Personal values must not cloud professional judgments Make no assumptions Take into account the client’s cultural and religious values and beliefs Pay attention to nonverbal communications Have clearly set goals Monitor your own reactions Copyright © 2023 by Elsevier, Inc. All rights reserved. 13  Data Collection (cont)  Psychosocial History  Client’s perception of own health, beliefs about wellness/illness  How client passes time (leisure activities)  Use of substances/substance use disorder  Stress level and coping abilities: usual coping strategies, support systems Cultural Beliefs and Practices  Identify client’s cultural health care beliefs, practices, values  Determine if there are any cultural factors that can affect client’s care Copyright © 2023 by Elsevier, Inc. All rights reserved. 14  Data Collection (cont)  Psychosocial History Spiritual and Religious Beliefs  Spiritual and religious beliefs affect how client finds meaning, hope, purpose, and sense of peace Copyright © 2023 by Elsevier, Inc. All rights reserved. 15  Data Collection (cont) Mental Status Exam  Physical Appearance  Behavior (voluntary/involuntary body movt, eye contact)  Cognitive and Intellectual abilities  Determine if oriented to time, person, place, circumstances  Check client’s memory (immediate, recent, remote)  Identify level of knowledge (what does client know about his illness)  Check ability to calculate (count backwards from 100 by 7s)  Determine ability to think abstractly  Determine client’s judgement  Check rate and volume of speech, quality of language Copyright © 2023 by Elsevier, Inc. All rights reserved. 16  Data Collection (cont) Mental Status Exam  Level of Consciousness  Alert  Lethargic  Stuporous  Comatose  Abnormal posturing in comatose posturing Copyright © 2023 by Elsevier, Inc. All rights reserved. 17  Data Collection (cont) Mini Mental State Exam  Orientation to time and place  Attention span and ability to calculate by counting backwards by seven  Registration and recalling of shapes  Language, including recalling names of objects, following commands, and ability to write Copyright © 2023 by Elsevier, Inc. All rights reserved. 18  The Health History – Physical Assessment  Performed to discover physical problems that can be treated medically  Many alterations in behavior related to physical cause  Review of each body system and its functioning  Clients are questioned about the following: General health care Past illnesses Hospitalizations Family health history  Questions then focus on the function of each body system  The lifestyle and activities of daily living also are assessed Copyright © 2023 by Elsevier, Inc. All rights reserved. 19