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Chapter: Psychiatric Mental Health Nursing : Assessment

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Content of the Assessment

The framework for psychosocial assessment discussed here and used throughout this textbook contains the following components: · History · General appearance and motor behavior · Mood and affect · Thought process and content · Sensorium and intellectual processes · Judgment and insight · Self-concept · Roles and relationships · Physiologic and self-care concerns

CONTENT OF THE ASSESSMENT

 

The information gathered in a psychosocial assessment can be organized in many different ways. Most assessment tools or conceptual frameworks contain similar categories with some variety in arrangement or order. The nurse should use some kind of organizing framework so that he or she can assess the client in a thorough and systematic way that lends itself to analysis and serves as a basis for the client’s care. The framework for psychosocial assessment discussed here and used throughout this textbook contains the following components:


·    History

 

·    General appearance and motor behavior

 

·    Mood and affect

 

·    Thought process and content

 

·    Sensorium and intellectual processes

 

·    Judgment and insight

 

·    Self-concept

 

·    Roles and relationships

 

·    Physiologic and self-care concerns

 


 

History

 

Background assessments include the client’s history, age and developmental stage, cultural and spiritual beliefs, and beliefs about health and illness. The history of the cli-ent, as well as his or her family, may provide some insight into the client’s current situation. For example, has the cli-ent experienced similar difficulties in the past? Has theclient been admitted to the hospital, and if so, what was that experience like? A family history that is positive for alcoholism, bipolar disorder, or suicide is significant because it increases the client’s risk for these problems.

 

The client’s chronological age and developmental stage are important factors in the psychosocial assessment. The nurse evaluates the client’s age and developmental level for congruence with expected norms. For example, a client may be struggling with personal identity and attempting to achieve independence from his or her parents. If the cli-ent is 17 years old, these struggles are normal and antici-pated because these are two of the primary developmental tasks for the adolescent. If the client is 35 years old and still struggling with these issues of self-identity and inde-pendence, the nurse will need to explore the situation. The client’s age and developmental level also may be incongru-ent with expected norms if the client has a developmental delay or mental retardation.

 

The nurse must be sensitive to the client’s cultural and spiritual beliefs to avoid making inaccurate assumptions about his or her psychosocial functioning (Schultz & Videbeck, 2009). Many cultures have beliefs and values about a person’s role in society or acceptable social or personal behavior that may differ from those of the nurse. Western cultures generally expect that as a person reaches adulthood, he or she becomes financially independent, leaves home, and makes his or her own life decisions. In contrast, in some Eastern cultures, three generations may live in one household, and elders of the family make major life decisions for all. Another example is the assessment of eye contact. Western cultures consider good eye contact to be a positive characteristic indicating self-esteem and pay-ing attention. People from other cultures, such as Japan, consider such eye contact to be a sign of disrespect.

 

The nurse must not stereotype clients. Just because a person’s physical characteristics are consistent with a par-ticular race, he or she may not have the attitudes, beliefs, and behaviors traditionally attributed to that group. For example, many people of Asian ancestry have beliefs and values that are more consistent with Western beliefs and values than with those typically associated with Asian countries. To avoid making inaccurate assumptions, the nurse must ask clients about the beliefs or health practices that are important to them or how they view themselves in the context of society or relationships.

The nurse also must consider the client’s beliefs about health and illness when assessing the client’s psychosocial functioning. Some people view emotional or mental prob-lems as family concerns to be handled only among family members. They may view seeking outside or professional help as a sign of individual weakness. Others may believe that their problems can be solved only with the right medi-cation, and they will not accept other forms of therapy. Another common problem is the misconception that one should take medication only when feeling sick. Many men-tal disorders, like some medical conditions, may require clients to take medications on a long-term basis, perhaps even for a lifetime. Just like people with diabetes must take insulin and people with hypertension need antihyperten-sive medications, people with recurrent depression may need to take antidepressants on a long-term basis.

 

General Appearance and Motor Behavior

 

The nurse assesses the client’s overall appearance, including dress, hygiene, and grooming. Is the client appropriately dressed for his or her age and the weather? Is the client unkempt or disheveled? Does the client appear to be his or her stated age? The nurse also observes the client’s posture, eye contact, facial expression, and any unusual tics or trem-ors. He or she documents observations and examples of behaviors to avoid personal judgment or misinterpretation. Specific terms used in making assessments of general appearance and motor behavior include the following:

 

·    Automatisms: repeated purposeless behaviors often in-dicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot

 

·    Psychomotor retardation: overall slowed movements

 

·    Waxy flexibility: maintenance of posture or position over time even when it is awkward or uncomfortable

 

The nurse assesses the client’s speech for quantity, qual-ity, and any abnormalities. Does the client talk nonstop? Does the client perseverate (seem to be stuck on one topic and unable to move to another idea)? Are responses a min-imal “yes” or “no” without elaboration? Is the content of the client’s speech relevant to the question being asked? Is the rate of speech fast or slow? Is the tone audible or loud? Does the client speak in a rhyming manner? Does the cli-ent use neologisms (invented words that have meaning only for the client)? The nurse notes any speech difficul-ties such as stuttering or lisping.

 

Mood and Affect

 

Mood refers to the client’s pervasive and enduring emo-tional state. Affect is the outward expression of the client’s emotional state. The client may make statements about feelings, such as “I’m depressed” or “I’m elated,” or the nurse may infer the client’s mood from data such as pos-ture, gestures, tone of voice, and facial expression. Thenurse also assesses for consistency among the client’s mood, affect, and situation. For instance, the client may have an angry facial expression but deny feeling angry or upset in any way. Or the client may be talking about the recent loss of a family member while laughing and smil-ing. The nurse must note such inconsistencies.

Common terms used in assessing affect include the following:

 

·    Blunted affect: showing little or a slow-to-respond fa-cial expression

 

·    Broad affect: displaying a full range of emotional expressions

 

·    Flat affect: showing no facial expression

 

·    Inappropriate affect: displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances

 

·    Restricted affect: displaying one type of expression, usually serious or somber.

 

The client’s mood may be described as happy, sad, depressed, euphoric, anxious, or angry. When the client exhibits unpredictable and rapid mood swings from depressed and crying to euphoria with no apparent stim-uli, the mood is called labile (rapidly changing).

 

The nurse may find it helpful to ask the client to esti-mate the intensity of his or her mood. The nurse can do so by asking the client to rate his or her mood on a scale of 1 to 10. For example, if the client reports being depressed, the nurse might ask, “On a scale of 1 to 10, with 1 being least depressed and 10 being most depressed, where would you place yourself right now?”

 

 

Thought Process and Content

 

Thought process refers to how the client thinks. The nurse can infer a client’s thought process from speech and speech patterns. Thought content is what the client actually says. The nurse assesses whether or not the client’s verbalizations make sense; that is, if ideas are related and flow logically from one to the next. The nurse also must determine whether the client seems preoccupied, as if talking or pay-ing attention to someone or something else. When the nurse encounters clients with marked difficulties in thought pro-cess and content, he or she may find it helpful to ask focused questions requiring short answers. Common terms related to the assessment of thought process and content include the following (American Psychiatric Association, 2000):

 

·    Circumstantial thinking: a client eventually answers a question but only after giving excessive unnecessary detail

 

·    Delusion: a fixed false belief not based in reality

 

·    Flight of ideas: excessive amount and rate of speech composed of fragmented or unrelated ideas

 

o   Ideas of reference: client’s inaccurate interpretation that general events are personally directed to him orher, such as hearing a speech on the news and believing the message had personal meaning

 

·    Loose associations: disorganized thinking that jumps from one idea to another with little or no evident rela-tion between the thoughts

 

·    Tangential thinking: wandering off the topic and never providing the information requested

 

·    Thought blocking: stopping abruptly in the middle of a sentence or train of thought; sometimes unable to con-tinue the idea

 

·    Thought broadcasting: a delusional belief that others can hear or know what the client is thinking

 

·    Thought insertion: a delusional belief that others are putting ideas or thoughts into the client’s head—that is, the ideas are not those of the client

 

·    Thought withdrawal: a delusional belief that others are taking the client’s thoughts away and the client is pow-erless to stop it

 

·    Word salad: flow of unconnected words that convey no meaning to the listener.

 

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