Also Read: Mental Status Examination, Mini Mental State Examination
Assessment
Assessment is the first step, involving critical thinking skills and data collection for both subject and objective cues. Data may come from the patient, family, significant others, caregivers, and even friends. Charts and other records may populate the data.
Psychosocial Assessment
An evaluation of an individual’s mental health and social well being. It begins with a general psychosocial history and ends with a Mental Status Examination.
- Initial Information: patient name, address, age, gender, etc.
- Presenting Problems: chief complaint/s; why is the client seeking help? What are some recent difficulties faced e.g. changes in interpersonal roles.
- General/Health History: hospitalization, self-care problems, medications, drug and alcohol use, employment, education, legal history
- Family History: familial physical, mental health problems, and drug use
- Response to Mental Health Problems: changes in relationships, roles, lifestyles, and self-concept.
- Risk Assessment (Suicide, Homicide): history or current expressions of self-directed or outward violent behavior.
- Ideation: “are you thinking about killing yourself?”
- Planning: “do you have a plan on how you would kill yourself?”
- Timing: “at what time of day or event would you kill yourself?”
- Access: “how would you carry out this plan?”
- Method: “how do you plan on killing yourself?”
- Where: “where would you kill yourself?”
- When: “when do you plan on killing yourself?”
- SAD PERSON’S Scale: answer each of the ten factors listed as present or absent and tally the number of present factors. 0 - 5 is may be discharged, 6 - 8 is may require psychiatric consultation, and 9 - 10 is may require admission. ==Recent studies have found this scale to be low-sensitivity, and may even be clinically harmful.==.
- Sex (Male), Age (<19, >45), and Depression are all risk factors for suicide.
- Previous attempt (major indicator), Ethanol or other substance abuse, Rational thought is lost, Social support is lacking, Organization of suicide plans, No spouse, and Sickness.
| Suicide Risk Factors | Homicide Risk Factors | |
|---|---|---|
| Previous Suicide Attempt | Male Gender | |
| Family History | Gang Affiliation | |
| History of Depression or BPD | Unemployment | |
| History of Aggressiveness or Impulsivity | Active Psychotic Symptoms | |
| Drug and Alcohol Abuse | Drug and Alcohol Abuse | |
| Feelings of Isolation | Low socioeconomic status | |
| Feelings of Hopelessness | ||
| Physical Illness | ||
| Unwillingness to seek help | ||
| Non-compliance |
- Psychosocial Development: identify the patient’s childhood development, adolescence (peer group), and drug use by the family.
- Manifestations
- Mood: a subjective feeling, only assessed through the patient’s words. Ask the patient how they are feeling or how their mood is.
- Affect: an objective form of mood; their displayed mood.
- Fluctuations: labile (changes rapidly), expansive (euphoria)
- Range: restricted
- Intensity: normal, blunted (decreased response), flattened (no emotion), elated (extreme also potentially with motor activity and speech), hyper-energized
- Quality: sad, anger, hostile, indifferent, euthymic (normal), dysphoric (pathologic sadness; depressed), detached, elated, euphoric, anxious (apprehension), animated, irritable
- Congruency between mood and affect should be noted i.e. a congruency of the patient stating feelings of distress while laughing; “inappropriate affect” is the disharmony between thought and emotional response.
- Thoughts: delusions (persecution, nihilism, broadcasting, withdrawal, insertion, ideas of reference, grandiosity, somatic delusions), obsessions, hypochondria, perseverance, circumstantiality, tangentiality, thought blocking, neologisms, loose association, word salad, clan association, flight of ideas, alogia
- Perception: illusions, hallucinations (gustatory, olfactory, visual, aural, tactile), depersonalization, derealization
- Motor Behavior: catatonia, waxy flexibility, automatism, stereotypy, tics and spasms.
- Memory: amnesia (retrograde, anterograde), paraamnesia (confabulation; voluntary/involuntary fabrication of stories, blackout), false memory, lethologica (inhibition of articulation and recalling of proper nouns).
- Deja (familiar, should be unfamiliar) or Jamais (unfamiliar, should be familiar) + Vu (event, situation, place) or Intendu (sounds): Deja Vu, Jamais Vu, Deja Intendu, Jamais Intendu
Mental Status Examination
- Appearance: general appearance, clothing, hygiene, characteristics, abnormalities
- Behavior: cooperation, activity level, social skills, motor activity
- Thought Content: what the client is saying; delusions, hallucinations, helplessness, hopelessness, worthlessness, suicidal or homicidal thoughts, suspiciousness, obsessions, denial, phobia
- Thought Process: what the client is thinking; bizarreness, logical, ambivalence, circumstantiality, tangentially, thought blocking, loose association, flight of ideas, perseveration, neologisms
- Thought Clarity: coherence, confusion, or vagueness
- Speech Pattern: amount, rate, volume, tone, pressure, mutism, stuttering, slurring
- Orientation: person, place, time, situation.
- Memory: recalling of distant or recent events
- Intellectual Functioning: educational level, attention, retention, abstract reasoning
- Cognitive Functioning: comprehension, interpreting data, learning data, judgment, perception, problem-solving, decision-making, reasoning
Gordon’s Functional Health Patterns
- Health Perception
- Nutrition and Metabolism
- Elimination
- Activity (Exercise)
- Cognitive (Perception)
- Sleep (Rest)
- Self-Concept or Self-Perception
- Role (Relationships)
- Sexuality (Reproduction)
- Coping (Stress Relievers)
- Values (Beliefs)
Other Assessment Tools
- Ethnocultural and Spiritual Assessment: assessment of the interconnected nature of culture and spirituality while recognizing uniqueness at the same time. This helps the patient gain a voice to express their sacred story.
- Personality Tests: assessment of character or character traits. These might gather self-report information.
- Thematic Apperception Test
- Projective Technique
- Approach Control Test
- Personality Processes
- Unobtrusive Measures
- Think-Aloud Protocol
- Rorschach Inkblot Test
- Picture-World Test
- Overdetermination Test
- Personality Assessment
- Psychological Assessment: broad-scope testing usually following standard psychoeducational and neuropsychological evaluations. The goals of these evaluations are typically to clarify diagnoses and inform treatment or intervention.
- Intelligence Testing: the theory and practice of measuring people’s performance on various diagnostic instruments to predict future behavior and life prospects or as a tool for identifying interventions.
Diagnosis
Formulation of a nursing diagnosis (a clinical judgment about responses to actual or potential health problems on part of the patient, family, or community) by employing clinical judgment in the planning and implementation of patient care. Nursing diagnoses are listed by the North American Nursing Diagnosis Association (NANDA). These diagnoses encompass Maslow’s Hierarchy of Needs:
- Basic Physiological Needs: nutrition, elimination, airway, etc.
- Safety and Security: injury prevention, climate of trust and safety, etc.
- Love and Belonging: supportive relationships, prevention of isolation, active listening, etc.
- Self-Esteem: acceptance, workforce, personal achievement, sense of control, etc.
- Self-Actualization: reaching one’s maximum potential, empowering environment, spiritual growth, perceptiveness, etc.
Planning
The stage where short and long-term goals and outcomes that directly impact the patient care based on EDP guidelines are formulated. Patient-specific goals assist in positive outcomes. Overall condition and comorbid conditions play a role in the construction of a care plan. Care plans enhance communication, documentation, reimbursement, and continuity of care across the healthcare continuum. Goals follow the SMART guidelines:
- Specific
- Measurable and Meaningful
- Attainable and Action-Oriented
- Realistic and Result-Oriented
- Timely or Time-Bound
| Nursing Outcome | Definition |
|---|---|
| Improved | Condition changed and/or recovered |
| Stabilized | Condition did not change and require further care to maintain condition |
| Deteriorated | Condition changed and worsened |
Implementation
Actual conduction of nursing interventions outlined in the plan of care e.g. cardiac monitoring, oxygen therapy, medications, and other standard treatment protocols. Therapeutic communication is applied, and a therapeutic relationship is developed. All care given in this stage is documented.
Evaluation
The final step, vital to a positive patient outcome. Evaluation or reassessment after intervention ensures that the desired outcome or progress has been met. The plan of care may then be adapted based on new assessment data.
Nursing Care Plan
| Assessment | Diagnosis | Background Knowledge | Planning |
|---|---|---|---|
| Subjective and Objective Cues | PES Format Nursing Diagnosis | Etiological Description | Goal-setting with SMART guidelines |
| Interventions | Rationale | Evaluation |
|---|---|---|
| Nursing actions based on goals of care | How interventions achieve goals of care | Statement and evidence of improvement |