Definition
- Accuracy in assessment determines whether the following steps of the nursing process will produce accurate nursing diagnoses, palnning, and intervention.
- Psychiatric-mental health assessment is the gathering, organizing, and documenting of data about the psychiatric and mental health needs of the client and family.
Assessment
- The first step of the nursing process.
Interview
- The degree to which the interview is therapeutic, or helpful, to the client may determine the extent and honesty of the information shared by the client.
- Clients expect the interviewer to be an expert who is confident in the professional role, maintains confidentiality, demonstrates warmth and genuineness, is nonjudgmental toward them and their past or current behavior, and recognizes that clients are experts on themselves and their behavior.
Assessment Data
- Subjective
- Client’s current problem and reason for seeking help.
- Past mental illness and treatment
- Family history and mental illness
- Medical history
- Allergies to medications, foods, and other substances
- Past and present medications and their effects
- Past and present abuse
- Substance abuse history
- Educational and/or vocational history
- Health habits
- Safety issues
- Cultural beliefs and practices
- Objective
- Behavior
- Communication
- Physical assessment
- Laboratory or testing data
- Mental status
Appearance
- Hygiene, grooming, appropriateness of clothing, posture, and gestures.
Behavior
- Eye contact, motor behavior, body language, behavioral responses to others and environment, volume and speed of speech, tone of voice, flow of words.
Affect and Mood
- Happy, sad, anxious, sullen, hostile, inappropriate for situation, silly, and range of emotions.
Orientation
- To person, place, time, situation, relationship with others.
Memory
- Immediate recall, recent and remote memory.
Sensorium or Attention
- Ability to concentrate on a task or conversation, perception of stimuli.
Intellectual functioning
- General fund of knowledge about the world, cognitive abilities such as a simple arithmetic.
- Ability to think abstractly or symbolically.
Judgement
- Decision making ability, especially regarding delay of gratification.
Insight
- Awareness of one’s responsibility for and analysis of current problem, understanding of how client arrived in current situation.
Thought Content
- Recurrent topics of conversation, themes.
Thought process
- Processing of events in the situation, awareness of one’s thoughts, logic of thought.
Perception
- Awareness of reality vs. fantasy, hallucinations, delusions, illusions, suicidal or homicidal ideation or plans.