After completing the psychosocial assessment, the nurse analyzes all the data that he or she has collected. Data analysis involves thinking about the overall assessment rather than focusing on isolated bits of information. The nurse looks for patterns or themes in the data that lead to conclusions about the client’s strengths and needs and to a particular nursing diagnosis. No one statement or behav-ior is adequate to reach such a conclusion. The nurse also must consider the congruence of all information provided by the client, family, or caregivers, as well as his or her own observations. It is not uncommon for the client’s percep-tion of his or her behavior and situation to differ from that of others. Assessments in a variety of areas are necessary to support nursing diagnoses such as Chronic Low Self-Esteem or Ineffective Coping.
Traditionally, data analysis leads to the formulation of nursing diagnoses as a basis for the client’s plan of care. Nursing diagnoses have been an integral part of the nurs-ing process for many years. With the sweeping changes occurring in health care, however, the nurse also must articulate the client’s needs in ways that are clear to health team members in other disciplines as well as to families and caregivers. For example, a multidisciplinary treatment plan or critical pathway may be the vehicle for planning care in some agencies. A plan of care that is useful to the client’s family for home care may be necessary. The nurse must describe and document goals and interventions thatmany others, not just professional nurses, can understand. The descriptions must contain no jargon or terms that are unclear to the client, family, or other providers of care.
Psychological tests are another source of data for the nurse to use in planning care for the client. Two basic types of tests are intelligence tests and personality tests. Intelligence tests are designed to evaluate the client’s cognitive abilities and intellectual functioning. Personality tests reflect the client’s personality in areas such as self-concept, impulsecontrol, reality testing, and major defenses (Adams & Culbertson, 2005). Personality tests may be objective (constructed of true-and-false or multiple-choice ques-tions). Table 8.1 describes selected objective personality tests. The nurse compares the client’s answers with stan-dard answers or criteria and obtains a score or scores.
Other personality tests, called projective tests, are unstructured and are usually conducted by the interview method. The stimuli for these tests, such as pictures or Rorschach’s inkblots, are standard, but clients may respond with answers that are very different. The evaluator ana-lyzes the client’s responses and gives a narrative result ofthe testing. Table 8.2 lists commonly used projective personality tests.
Both intelligence tests and personality tests are fre-quently criticized as being culturally biased. It is impor-tant to consider the client’s culture and environment when evaluating the importance of scores or projections from any of these tests; they can provide useful information about the client in some circumstances but may not be suitable for all clients.
Medical diagnoses of psychiatric illness are found in the Diagnostic and Statistical Manual of Mental Disorders, 4th edition, Text Revision (DSM-IV-TR). This taxonomy is uni-versally used by psychiatrists and by some therapists in the diagnosis of psychiatric illnesses. The DSM-IV-TR clas-sifies mental disorders into categories. It describes each disorder and provides diagnostic criteria to distinguishone from another. Although the DSM-IV-TR is not a substi-tute for a thorough psychosocial nursing assessment, the descriptions of disorders and related behaviors can be a valuable resource for the nurse to use as a guide. The DSM-IV-TR uses a multiaxial system to provide the format for a complete psychiatric diagnosis:
· Axis I: clinical disorders, other conditions that may be a focus of clinical attention
· Axis II: personality disorders, mental retardation
· Axis III: general medical conditions
· Axis IV: psychosocial and environmental problems
· Axis V: global assessment of functioning (GAF).
The psychosocial and environmental problems categorized on axis IV include educational, occupational, housing, finan-cial, and legal problems as well as difficulties with the social environment, relationships, and access to health care.
The GAF is used to make a judgment about the client’s overall level of functioning. The GAF score given to the client may describe his or her current level of func-tioning as well as the highest level of functioning in the past year or 6 months. This information is useful in setting appropriate goals for the client’s care.
Often, psychiatrists, therapists, or other clinicians perform a cursory abbreviated exam that focuses on the client’s cognitive abilities. These exams usually include items such as orientation to person, time, place, date, season, and day of the week; ability to interpret proverbs; ability to per-form math calculations; memorization and short-term recall; naming common objects in the environment; ability to follow multistep commands; and ability to write or copy a simple drawing. The fewer tasks the client completes accurately, the greater the cognitive deficit. Because this exam assesses cognitive ability, it is often used to screen for dementia. However, cognition may also be impaired (usually temporarily) when clients are depressed or psychotic.