Chapter 9Assessment of
Psychiatric–Mental Health
Clients
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
The first step in the nursing process, the
assessment of the client, is crucial. Assess
the client in a holistic way, integrating any
relevant information about the client’s life,
behavior, and feelings. Remember that the
focus of care, beginning with the initial
assessment, is toward the client’s optimum
level of health and independence from the
hospital.
Schultz and Videbeck, 2009
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Learning Objectives
After studying this chapter, you should be able to
•
Discuss the nursing process
•
Articulate the purpose of a comprehensive nursing
assessment
•
Differentiate the purpose of a focused and a screening
assessment
•
Understand the significance of cultural competence
during the assessment process
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Learning Objectives (cont.)
•
Recognize how disturbances in communication
exhibited by a client can impair the assessment
process
•
Describe the importance of differentiating among
the six types of delusions during the assessment
process
•
Distinguish the five types of hallucinations
identified in psychiatric disorders
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Learning Objectives (cont.)
•
Illustrate the differences between obsessions and
compulsions
•
Discriminate levels of orientation and
consciousness during the assessment process
•
Reflect on how information obtained during the
assessment process is transmitted to members of
the health care team
•
Formulate the criteria for documentation of
assessment data
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Six Steps of the Nursing Process

Assessment

Nursing diagnosis

Outcome identification

Planning (formulation of a plan of nursing care)

Implementation of nursing actions or interventions

Evaluation of the client’s response to interventions
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
The assessment phase of the nursing process
includes nurse–client interaction during the
collection of data about a person, family, or
group by the methods of observing, examining,
and interviewing.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Client Assessment
Types of Data
Types of Assessment
• Objective data
• Subjective data
• Comprehensive assessments
• Focused assessments
• Screening assessments
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Cultural Competence During Assessment
(Mackey-Padilla, 2005; Kanigel, 1999)







Assess and clarify the client’s cultural values, beliefs, and
norms.
Assess the client’s degree of cultural
assimilation/acculturation.
Assess the client’s perspective regarding feelings and
symptoms.
Elicit the client’s expectations and ask what is important for
the health care provider to know.
Learn how to work with interpreters.
When using an interpreter, talk to the client rather than the
interpreter.
Seek collaboration with bilingual community resources.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Collection of Data
• Appearance
• Memory
• Affect or emotional state
• Intellectual ability
• Behavior, attitude, and
coping patterns
• Insight regarding illness
• Communication and social
skills
• Content of thought
• Spirituality
• Sexuality
• Neurovegetative changes
• Orientation
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Impaired Communication
• Blocking
• Mutism
• Circumstantiality
• Neologism
• Clang association
• Perseveration
• Echolalia
• Tangentiality
• Flight of ideas
• Verbigeration
• Looseness of association
• Word salad
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Content of Thought
• Delusions
• Hallucinations
• Depersonalization
• Obsessions
• Compulsions
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Sleep Pattern
Asking clients about their sleep patterns and any
problems is an often neglected, but extremely
important, area to investigate.
• Insomnia
• Acute or primary insomnia
• Secondary insomnia
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Medical Issues
• Pain
• Physiological responses to medication
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Supporters or Caregivers Assessment
• Informal supporters or caregivers are prone to
depression, anxiety, grief, fatigue, changes in social
relationships, or other issues.
• Strain related to care provision may affect employment,
financial, physical, social, and time domains.
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Documentation of Assessment Data
• Objective
• Dated
• Descriptive
• Logical
• Complete
• Signed
• Legible
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key Terms
• Acute insomnia
• Delusions
• Affect
• Depersonalization
• Blocking
• Echolalia
• Circumstantiality
• Flight of ideas
• Clang association
• Hallucinations
• Compulsions
• Illusion
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Key Terms
• Insight
• Nursing process
• Insomnia
• Obsessions
• Looseness of association
• Perseveration
• Memory
• Secondary insomnia
• Mutism
• Tangentiality
• Neologism
• Verbigeration
• Neurovegetative changes
• Word salad
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
Reflection
Complete an assessment of a client in your clinical
practice setting.
• What information did you
obtain?
• How was that information
crucial to the client’s care?
Copyright © 2012 Wolters Kluwer Health | Lippincott Williams & Wilkins
?