Unit 3 Mental Status, Psychosocial, Spirituality & Pain Assessment 2024 PDF

UNIT 3: ASSESSMENT OF HEALTH STATUS (SYSTEMATIC APPROACH) Mental Status, Psychosocial, Spirituality & Pain Assessment PRESENTED BY: MRS. KERON JONES-FRASER, PHD CANDIDATE, MSCN, BSCN, CERT ED, RN OBJECTIVES At the end of three hours adult learners will: Describe the menta...

UNIT 3: ASSESSMENT OF HEALTH STATUS (SYSTEMATIC APPROACH) Mental Status, Psychosocial, Spirituality & Pain Assessment PRESENTED BY: MRS. KERON JONES-FRASER, PHD CANDIDATE, MSCN, BSCN, CERT ED, RN OBJECTIVES At the end of three hours adult learners will: Describe the mental status assessment of clients Explain how client’s psychosocial status is assessed State the importance of and describe the spiritual assessment of clients Review the techniques used in assessing pain  Assessment Preparation: Ensure that environment is appropriate and conducive (including privacy, lighting and ventilation) Ensure client’s comfort Reassure client that data collected will be held in strict confidence (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018)  Mental Status Assessment This examination helps in determining the client’s emotional and cognitive functional statuses. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Observe level of consciousness Call client by name and observe the response Call louder, if the client does not respond Gently shake client and observe the response Apply painful stimulus, if the client does not respond (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Findings: Client is alert and awake when eyes are open and focused on the examiner and responds appropriately. Lethargy: Client opens eyes, answers questions, and then falls asleep Obtunded: Client opens eyes to loud voice, responds slowly with confusion, seems unaware of environment Stupor: Client awakens to vigorous shake or painful stimuli but returns to unresponsive sleep. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Findings: Coma: client remains unresponsive to all stimuli, eyes remain closed. Decorticate or abnormal flexor posture (draws hands to chest) describes the client's response to stimuli who have lesions of the corticospinal tract Decerebrate or abnormal extensor posture (extends arms and legs, arches neck and rotates hands and arms internally) Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment (Kozier, Erb, Berman & Snyder, 2008) (Weber & Kelley, 2007) Mental Status Assessment Observe posture and body movements Normal findings – client appears relaxed with shoulders and back erect when standing or sitting Abnormal findings – slumped posture may reflect feelings of powerlessness or hopelessness characteristic of depression or organic brain disease - prolonged, euphoric laughing is typical of mania Bizarre body movements and behaviour may suggest schizophrenia or side effect of drug therapy (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Observe dress, grooming, and hygiene Normal findings – client is appropriately dressed for the occasion and or weather, skin is clean, hair and nails are neat and trimmed Abnormal findings – unusually meticulous grooming or poor hygiene and inappropriate dress may be indicative of obsessive- compulsive disorder or depression for example. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Observe facial expressions Normal findings – client maintains good eye contact, smiles and frowns appropriately Abnormal findings – poor eye contact may suggest depression, extreme facial expressions of happiness, anger, or fright may be seen in anxious clients. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Observe speech for tone, clarity, and pace and speech. Normal findings – speech is in a moderate tone, clear, and with moderate pace. Abnormal findings – slow, repetitive speech is characteristic of depression or Parkinson’s disease. Loud, rapid speech may occur in manic phases of bipolar disorder. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Observe mood, feelings, and expressions Normal findings – client is cooperative friendly, expresses positive feelings about others and the future and positive coping mechanisms. Abnormal findings - expression of worry or prolonged negative, gloomy feelings, or Expression of elation and grandiosity ((Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Observe thought processes and perceptions Normal findings: Client expresses positive, healthy thoughts about the future and self and follows directions accurately. Abnormal findings: Client exhibits illogical thoughts, invention of thoughts, rapid flight of ideas, suicidal ideation. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Mental Status Assessment Observe cognitive abilities Orientation (person, place and time) Concentration Recent memory Remote memory (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018)  Mental Status Assessment Use of memory to learn new information Have client repeat four unrelated words in 5 minutes, again 10 minutes and again in 30 minutes. Abstract reasoning Ask client to compare objects or explain a proverb correctly. (the client may lack the ability to do this due to schizophrenia, mental retardation, delirium and dementia). (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018)  Mental Status Assessment Judgement Present client with a scenario and ask him/her what they would do in a specific situation (for example: “what would you if you lost the keys to your house?). (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018)  Mental Status Assessment Visual perception and constructional ability Ask the client to draw the face of a clock or copy simple figures (failure to do so is suggestive of mental retardation, dementia) (Kozier, Erb, Berman & Snyder, 2018) (Weber & Kelley, 2018) Mini-Mental Status Examination The Mini-Mental Status Examination offers a quick and simple way to quantify cognitive function and screen for cognitive loss. It tests the individual's orientation, attention, calculation, recall, language and motor skills. Mental Status Assessment, continued Mental Status Assessment, continued Mental Status Assessment, continued Mental Status Assessment, continued Mental Status Assessment, continued Mental Status Assessment, continued Psychosocial Assessment Psychosocial Assessment https://www.youtube.com/watch?v=aYCBdZLCDBQ  Psychosocial Assessment Erikson’s 8 stages of psychosocial development Stage 1: infant 0-18 months Trust vs mistrust Observe for existence of bond between child and parent/caregiver Does the parent/caregiver console the child easily? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 2: Toddler 18 months – 3 years Autonomy vs. shame and doubt Observe for display of individuality separation from parents control over bodily functions Communication with words Practising socially acceptable behaviour Self-centred interactions with others (Weber & Kelley, 2018)  Psychosocial Assessment Stage 2: Toddler 18 months – 3 years Autonomy vs. shame and doubt Sample interview questions Does your toddler dress or feed him/herself or try doing so? How well does your child communicate with you and others, are temper tantrums often? Is your toddler toilet trained? Is your toddler curious and actively explores his/her environment (Weber & Kelley, 2018)  Psychosocial Assessment Stage 3: Pre-schooler 3 – 5 years Imitative vs. guilt Sample interview questions – Does your pre-schooler have an active imagination? Imitate adult activities? Engage in fantasy play? Frequently as questions? Enjoy new activities? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 4: School age child 6 to 12 or 5 to 13 years Industry vs. Inferiority Sample interview questions – What are the child’s interests/hobbies, favourite activity? Does the child interact well with peers, and persons in authority (for example, teachers)? Does the child enjoy accomplishments? How does the child handle failure? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 5: Adolescent 13 to 18 years Identity vs. role confusion Sample interview questions – Does the adolescent have a peer group? Have a best friend? Exhibit rebellious behaviour? Have goals/aspirations, what are they? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 6: Young adult 21 to 39 years Intimacy vs isolation Sample interview questions: Is the client self-accepting? Does the client have independence from parental home? Express love responsibly, emotionally, and sexually? Have a close or intimate relationship with a partner? Have a social group of friends? Have a philosophy about living ad life? Have a career or is gain fully employed? Psychosocial Assessment Stage 7: Middle aged adult 40 to 65 years Generativity vs stagnation Does the client have healthy life patterns? Feel satisfied with his/her contribution to growth and development of others? Maintain a stable home? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 7: Middle aged adult 40 to 65 years Generativity vs stagnation Does the client Have abiding intimacy or long-term relationship with a partner? Take pride in self and family accomplishments and contributions? Contribute to the community to support its growth and development? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 8: Older adult 65 years and older ego integrity vs despair Does the client recognise and adjust to the changing physical self: due to aging, in relationships and activities? Maintain relationships with children, grandchildren and other relatives? Continue interests outside of self and home? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 8: Older adult 65 years and older ego integrity vs despair Does the client Complete transition from retirement at work to satisfying alternative activities? Establish relationships with others his or her own age? Adjust to deaths of relatives, spouse, and friends? (Weber & Kelley, 2018)  Psychosocial Assessment Stage 8: Older adult 65 years and older ego integrity vs despair Does the client Maintain a maximum level of physical functioning through diet, exercise and personal care? Find meaning in past life and face inevitable mortality of self and significant others? (Weber & Kelley, 2018) Pain Assessment The World Health Organisation defines pain as “an unpleasant sensory or emotional experience associated with actual or potential tissue damage or described in terms of such damage”. Pain is summarized by the processes of transduction, transmission, modulation, and perception. (Weber & Kelley, 2018) Pain Assessment Pain may be classified as acute, chronic non- malignant and cancer pain. Acute pain refers to that associated with and injury with a recent onset and duration of less than 6 months and usually less than a month. (Weber & Kelley, 2018) Pain Assessment Chronic non-malignant pain is usually associated with a specific cause or injury and is described as a constant pain that persists more than 6 months. Cancer pain is often due to the compression of peripheral nerves and meninges or from the damage to these structures following surgery, chemotherapy, radiation, or tumour growth and infiltration (Weber & Kelley, 2018) Pain Assessment Pain receptors are also located in the peritoneal surfaces, pleural membranes, dura mater, and blood vessel walls but not found in the parenchyma of visceral organs (Weber & Kelley, 2018) Pain Assessment COLDSPA Character – sign/symptom. How does it feel? Onset – when did it begin? Location – where is it? Does it radiate? Duration – how long does it last? Does it recur? Severity – how bad is it? (Pain severity scale) Pattern – what makes it better? What makes it worse? Associated factors – what other symptoms occur with it? (Weber & Kelley, 2018) Spirituality vs Religion Spirituality is defined as a search for meaning and purpose in life. (Weber & Kelley, 2018) Religion is defined as the rituals, practices, and experiences shared within a group that involve a search for the sacred (for example, God, Allah, etc.) that is shared within a group. (Weber & Kelley, 2018) Spirituality Assessment Why assess spirituality? Spirituality Assessment Spirituality assessment is the active and ongoing conversation that assesses the spiritual needs of the client. Plans for referral or intervention may develop as a result of ongoing dialogue between the nurse and the client. (Kozier, Erb, Berman & Snyder, 2018 ; Weber & Kelley, 2018) Spirituality Assessment The belief is popular that religion and spirituality have been related to greater well being in chronic disease management and end of life issues. Religion and spirituality, among certain populations, have been related to lower levels of stress, less depression, lower blood pressure, lower levels of mortality, less heart disease, less use of tobacco and alcohol abuse and positive health habits and greater well-being and optimism (Koenig, McCullough, & Larson, 2001 as cited in Weber & Kelley, 2018). Spirituality Assessment There are religious views, however, that negatively impact health. Among the examples are: Failure to seek health care in a timely manner The refusal of blood transfusion (Koenig, McCullough, & Larson, 2001; Barrett, Kurlan, & Johnson, 2001 as cited in Weber & Kelley, 2018) Spirituality Assessment SPIRITUAL ASSESSMENT TOOL – FICA© An acronym which can be used to remember what to ask in a spiritual history is: F: Faith or Beliefs I: Importance and Influence C: Community A: Address (Weber & Kelley, 2018) Spirituality Assessment Some specific questions you can use to discuss these issues are: F: What is your faith or belief? Do you consider yourself spiritual or religious? What things do you believe in that give meaning to your life? (Weber & Kelley, 2018) Spirituality Assessment I: Is it important in your life? What influence does it have on how you take care of yourself? How have your beliefs influenced your behaviour during this illness? What role do your beliefs play in regaining your health? (Weber & Kelley, 2018) Spirituality Assessment C: Are you part of a spiritual or religious community? Is this of support to you and how? Is there a person or group of people you really love or who are really important to you? (Weber & Kelley, 2018) Spirituality Assessment A: How would you like me, your healthcare provider to address these issues in your healthcare? (Weber & Kelley, 2018)  Spirituality Assessment General recommendations when taking a spiritual history: 1. Consider spirituality as a potentially important component of every patient’s physical well being and mental health. Spirituality Assessment General recommendations when taking a spiritual history, continued 2. Address spirituality at each complete physical exam and continue addressing it at follow-up visits if appropriate. In patient care, spirituality is an on-going issue. 3. Respect a patient’s privacy regarding spiritual beliefs; don’t impose your beliefs on others. Spirituality Assessment General recommendations when taking a spiritual history, continued 4. Make referrals to chaplains, spiritual directors or community resources as appropriate. 5. Be aware that your own spiritual beliefs will help you personally and will overflow in your encounters with those for whom you care to make the [nurse]-patient encounter a more humanistic one. (Puchalski, 2001 as cited in Weber & Kelley, 2018) Reference Kozier, B., Erb, G., Berman, A, & Snyder, S. (2018). Fundamentals of nursing: Concepts, processes, and practice. Pearson Prentice Hall. Weber, J., & Kelley, J. (2018). Health assessment in nursing. Lippincott, Williams & Wilkinson