ASSESSMENT OF SUICIDE OR HARM TOWARD OTHERS
The nurse must determine whether the depressed or hope-less client has suicidal ideation or a lethal plan. The nurse does so by asking the client directly, “Do you have thoughts of suicide?” or “What thoughts of suicide have you had?”
Likewise, if the client is angry, hostile, or making threat-ening remarks about a family member, spouse, or anyone else, the nurse must ask if the client has thoughts or plans about hurting that person. The nurse does so by question-ing the client directly:
· What thoughts have you had about hurting (person’s name)?
· What is your plan?
· What do you want to do to (person’s name)?
When a client makes specific threats or has a plan to harm another person, health-care providers are legally obligated to warn the person who is the target of the threats or plan. The legal term for this is duty to warn. This is one situation in which the nurse must breach the client’s con-fidentiality to protect the threatened person.
Orientation refers to the client’s recognition of person, place, and time—that is, knowing who and where he or she is and the correct day, date, and year. This is often documented as “oriented 3 3.” Occasionally, a fourth sphere, situation, is added (whether or not the client accurately perceives his or her current circumstances). Absence of correct information about person, place, and time is referred to as disorienta-tion, or “oriented 3 1” (person only) or “oriented 3 2” (person and place). The order of person, place, and time is significant. When a person is disoriented, he or she first loses track of time, then place, and finally person. Orienta-tion returns in the reverse order: first, the person knows who he or she is, then realizes place, and finally time.
Disorientation is not synonymous with confusion. A confused person cannot make sense of his or her sur-roundings or figure things out even though he or she may be fully oriented.
The nurse directly assesses memory, both recent and remote, by asking questions with verifiable answers. For example, if the nurse asks, “Do you have any memory problems?” the client may inaccurately respond “no,” and the nurse cannot verify that. Similarly, if the nurse asks, “What did you do yesterday?” the nurse may be unable to verify the accuracy of the client’s responses. Hence, questions to assess memory generally include the following:
· What is the name of the current president?
· Who was the president before that?
· In what county do you live?
· What is the capital of this state?
· What is your social security number?
The nurse assesses the client’s ability to concentrate by asking the client to perform certain tasks:
· Spell the word world backward.
· Begin with the number 100, subtract 7, subtract 7 again, and so on. This is called “serial sevens.”
· Repeat the days of the week backward.
· Perform a three-part task, such as “Take a piece of paper in your right hand, fold it in half, and put it on the floor.” (The nurse should give the instructions at one time.)
When assessing intellectual functioning, the nurse must consider the client’s level of formal education. Lack of for-mal education could hinder performance in many tasks in this section of the assessment.
The nurse assesses the client’s ability to use abstract think-ing, which is to make associations or interpretations about a situation or comment. The nurse usually can do so by asking the client to interpret a common proverb such as “a stitch in time saves nine.” If the client can explain the proverb cor-rectly, his or her abstract thinking abilities are intact. If the client provides a literal explanation of the proverb and can-not interpret its meaning, abstract thinking abilities are lack-ing. When the client continually gives literal translations, this is evidence of concrete thinking. For instance,
· Proverb: A stitch in time saves nine.
Abstract meaning: If you take the time to fix something now, you’ll avoid bigger problems in the future.
Literal translation: Don’t forget to sew up holes in your clothes (concrete thinking).
· Proverb: People who live in glass houses shouldn’t throw stones.
Abstract meaning: Don’t criticize others for things you also may be guilty of doing.
Literal translation: If you throw a stone at a glass house, the glass will break (concrete thinking).
The nurse also may assess the client’s intellectual func-tioning by asking him or her to identify the similarities between pairs of objects, for example, “What is similar about an apple and an orange?” or “What do the newspa-per and the television have in common?”
Some clients experience hallucinations (false sensory perceptions or perceptual experiences that do not really exist). Hallucinations can involve the five senses and bodily sensations. Auditory hallucinations (hearing voices) are the most common; visual hallucinations (see-ing things that don’t really exist) are the second most common. Initially, clients perceive hallucinations as real experiences, but later in the illness, they may recognize them as hallucinations.
Judgment refers to the ability to interpret one’s environ ment and situation correctly and to adapt one’s behavior and decisions accordingly. Problems with judgment may be evidenced as the client describes recent behavior and activ- ities that reflect a lack of reasonable care for self or others. The nurse also may assess a client’s judgment by asking the client hypo-thetical questions, such as “If you found a stamped addressed envelope on the ground, what would you do?”
Insight is the ability to understand the true nature of one’s situation and accept some personal responsibility for that situation. The nurse frequently can infer insight from the client’s ability to describe realistically the strengths and weaknesses of his or her behavior. An example of poor insight would be a client who places all blame on others for his own behavior, saying, “It’s my wife’s fault that I drink and get into fights, because she nags me all the time.” This client is not accepting respon-sibility for his drinking and fighting. Another example of poor insight would be the client who expects all problems to be solved with little or no personal effort: “The prob-lem is my medication. As soon as the doctor gets the med-ication right, I’ll be just fine.”
Self-concept is the way one views oneself in terms of per-sonal worth and dignity. To assess a client’s self-concept, the nurse can ask the client to describe himself or herself and what characteristics he or she likes and what he or she would change. The client’s description of self in terms of physical characteristics gives the nurse information about the client’s body image, which is also part of self-concept.
Also included in an assessment of self-concept are the emotions that the client frequently experiences, such as sadness or anger, and whether or not the client is comfort-able with those emotions. The nurse also must assess the client’s coping strategies. He or she can do so by asking, “What do you do when you have a problem? How do you solve it? What usually works to deal with anger or disappointment?”
People function in their community through various roles such as mother, wife, son, daughter, teacher, secretary, or volunteer. The nurse assesses the roles the client occupies, client satisfaction with those roles, and whether the client believes he or she is fulfilling the roles adequately. The number and type of roles may vary, but they usually include family, occupation, and hobbies or activities. Family roles include son or daughter, sibling, parent, child, and spouse or partner. Occupation roles can be related to a career or school or both. The ability to fulfill a role or the lack of a desired role is often central to the client’s psychosocial functioning. Changes in roles also may be part of the cli-ent’s difficulty.
Relationships with other people are important to one’s social and emotional health. Relationships vary in terms of significance, level of intimacy or closeness, and intensity. The inability to sustain satisfying relationships can result from mental health problems or can contribute to the worsening of some problems. The nurse must assess the relationships in the client’s life, the client’s satisfaction with those relationships, or any loss of relationships. Com-mon questions include the following:
· Do you feel close to your family?
· Do you have or want a relationship with a significant other?
· Are your relationships meeting your needs for compan-ionship or intimacy?
· Can you meet your sexual needs satisfactorily?
· Have you been involved in any abusive relationships?
If the client’s family relationships seem to be a signifi-cant source of stress or if the client is closely involved with his or her family, a more in-depth assessment of this area may be useful.
When doing a psychosocial assessment, the nurse must include physiologic functioning. Although a full physical health assessment may not be indicated, emotional prob-lems often affect some areas of physiologic function. Emotional problems can greatly affect eating and sleeping patterns: Under stress, people may eat excessively or not atall and may sleep up to 20 hours a day or may be unable to sleep more than 2 or 3 hours a night. Clients with bipolar disorder may not eat or sleep for days. Clients with major depression may not be able to get out of bed. Therefore, the nurse must assess the client’s usual patterns of eating and sleeping and then determine how those patterns have changed.
The nurse also asks the client if he or she has any major or chronic health problems and if he or she takes pre-scribed medications as ordered and follows dietary recom-mendations. The nurse also explores the client’s use of alcohol and over-the-counter or illicit drugs. Such ques-tions require nonjudgmental phrasing; the nurse must reassure the client that truthful information is crucial in determining the client’s plan of care.
Noncompliance with prescribed medications is an important area. If the client has stopped taking medication or is taking medication other than as prescribed, the nurse must help the client feel comfortable enough to reveal this information. The nurse also explores the barriers to com-pliance. Is the client choosing noncompliance because of undesirable side effects? Has the medication failed to pro-duce the desired results? Does the client have difficulty obtaining the medication? Is the medication too expensive for the client?