Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Chapter 8 Assessment

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Psychosocial Assessment Purpose –Picture of patient’s current emotional state, mental capacity, behavioral function –Basis for developing plan of care –Clinical baseline to evaluate effectiveness of treatment or measure patient’s progress

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Factors Influencing Assessment Patient participation/feedback Patient’s health status Patient’s previous experiences/misconceptions about health care Patient’s ability to understand Nurse’s attitude, approach

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Interview Environment –Comfortable, private, safe –Quiet with few distractions Input from family, friends (patient’s permission necessary) –Information about their perceptions of patient

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins The Interview (cont.) Questions –Open-ended to initiate assessment –Focused if patient unable to organize thoughts or has difficulty answering open-ended questions

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content History (see Box 8.1) –Age –Developmental stage –Cultural considerations –Spiritual beliefs –Previous history

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement true or false? When interviewing a patient, the nurse should select an area that is quiet and isolated from others.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: The nurse should interview a patient in an environment that is comfortable, private, and safe for both the patient and nurse. –The nurse should not choose an isolated location.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Appearance/motor behavior –Hygiene/grooming –Appropriate dress –Posture –Eye contact –Unusual movements/mannerisms Automatisms, psychomotor retardation, waxy flexibility – Speech (neologisms)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Mood/affect –Expressed emotions/facial expressions Blunted Broad Flat Inappropriate Restricted

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Thought process/content –Content (what) and process (how) Circumstantial thinking Delusion/flight of ideas/ideas of reference Loose associations/tangential thinking Thought broadcasting, insertion, blocking, withdrawal Word salad

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Thought process/content –Clarity of ideas –Self-harm or suicide urges (see Box 8.2)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Sensorium/intellectual processes –Orientation/confusion –Memory –Abnormal sensory experiences or misperceptions –Concentration –Abstract thinking abilities

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Judgment/insight –Judgment (interpretation of environment) –Decision-making ability –Insight (understanding one’s own part in current situation)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Self-concept –Personal view of self –Description of physical self –Personal qualities or attributes Roles/relationships –Current roles –Satisfaction with roles –Success at roles –Significant relationships –Support systems (see Box 8.3)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Which of the following would the nurse include when assessing a patient’s self-concept? –A. Roles –B. Support systems –C. Personal qualities –D. Abstract thinking

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer C. Personal qualities Rationale: Assessment of the patient’s self-concept includes information about the patient’s personal view of self, a description of physical self, and his or her personal qualities or attributes. –Roles and support systems are addressed when assessing the patient’s roles and relationships. Abstract thinking is addressed when assessing the patient’s sensorium and intellectual processes.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Assessment Content (cont.) Physiologic and self-care considerations –Eating habits –Sleep patterns –Health problems –Compliance with prescribed medications –Ability to perform activities of daily living

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Analysis Overall assessment data –Not isolated bits of information –Patterns or themes in data → nursing diagnoses Psychological tests Psychiatric diagnoses Mental status exam

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Analysis: Psychological Tests Intelligence tests –Cognitive abilities –Intellectual functioning Personality tests –Self-concept, impulse control, reality testing, major defense mechanisms –Objective (see Table 8.1) –Projective (see Table 8.2)

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Analysis: Psychiatric Diagnoses Diagnostic and Statistical Manual of Mental Disorders (DSM) –The DSM classifies psychiatric disorders into categories. –The DSM describes each disorder and provides the diagnostic criteria for each disorder.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Data Analysis: Mental Status Exam Patient’s cognitive abilities –Orientation to person, time, place, date, season, day of the week –Interpretation of proverbs –Math calculations –Memorization, short-term recall –Identification of common objects –Ability to follow multistep commands –Ability to write or copy a simple drawing

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Question Is the following statement is true or false? Personality tests measure a person’s cognitive abilities.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Answer False Rationale: Personality tests reflect the patient’s personality in areas such as self-concept, impulse control, reality testing, and major defenses. –Intelligence tests evaluate the patient’s cognitive abilities and intellectual functioning.

Copyright © 2014 Wolters Kluwer Health | Lippincott Williams & Wilkins Self-Awareness Issues Gather all information needed. –Judgments not part of assessment process Be open, clear, direct when asking about personal or uncomfortable topics. Examine own beliefs; gain self-awareness (growth- producing experience). Do not allow personal beliefs to interfere with nurse– patient relationship and assessment process.