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Assessment in this setting
  • Much of assessment will be observation only
  • You will observe the pt and their interactions with the pt
  • you will briefly review the medical record with a focus on symptoms, meds and assessment
Psychosocial Assessment
  • Purpose:
  • develop a picture of the client's current emotional state, mental capacity, and behavioral function
  • basis for deveoping plan of care
  • clinical baseline to evaluate effectiveness of treatment or measure client's progress
Factors Influencing Assessment
  • client participation and feedback
  • clients health status
  • clients previous experience or misconceptions about health care
  • clients ability to understand
  • Nurse's attitude, approach
The interview
  • Enviroment: comfortable, private, safe, quiet with few distractions
  • Input from famil and friends (with clients permission) about their perceptions of the client
  • Use open ended questions to initiate assessment
  • use focused questions if the client is unable to prganize thoughts or has difficulty answering open ended questions
Assessment Organization
  • Data sheet matches categories outlined in text
  • It reflects what is in assessment tools in the clinical setting
  • data sheets also include: psych and nursing dx, symptoms, medications, labs and relevant data
Assessment content: history
  • age
  • developmental stage
  • cultural considerations
  • spiritual beliefs
  • history
Assessment content: appearance and motor behavior
  • Appearance and motor behavior:
  • hygeine/grooming
  • appropriate dress
  • posture
  • eye contact
  • unusual movements and mannerisms (automatisms, psychomotor retardation, waxy flexibility)
  • Speech (neologisms)
Assessmenet content: Mood/Affect
  • Expressed emotions and facial expressions
  • blunted
  • broad
  • flat
  • inappropriate
  • restricted
Assessment content: thought process and content
  • content (what they say)
  • process (how they say it)
  • circumstantial thinking
  • deleusions, flight of ideas, ideas of reference
  • loose associations and tangential thinking
  • thought broadcasting
  • insertion, blocking, withdrawal
  • word salad
  • clarity of ideas
  • self harm or suicide urges
Assessment content: sensorium and intellectual processes
  • Orientation/confusion
  • memory
  • abnormal sensory experience or misperception
  • concentration
  • abstract thinking abilities (MMSE, CLOX)
Assessment content: judgement and insight
  • judgement (interpretation of enviroment)
  • decision making ability
  • insight (understanding one's own part in current situation)
Assessment content: self concept
  • personal view of self
  • description of physical self
  • personal qualities or attributes
Assessment content: roles and relationships
  • current roles
  • satisfaction with roles
  • success at roles
  • significant relationships
  • support systems
Assessment content: physiologic and self care considerations
  • eating habits
  • sleep patterns
  • health problems
  • compliance with prescribed meds
  • ability to perform ADLs
Data Analysis
  • overall assessment data, not isolated bits of information
  • use patterns or themes of data to develop nursing dx
  • psych tests
  • psych dx
  • mental status exam
Data Analysis: psych dx
  • DSM-IV-TR multiaxial system
  • Axis I: clinical disorders, other conditions possibly a focus of clinical attention
  • Axis II: personality disorders, mental retardation
  • Axis III: general medical conditions
  • Axis IV: psychosocial, enviromental problems
  • Axis V: GAF
Data Analysis: MMSE
  • Evaluates pt's cognitive abilities
  • Orientation x4
  • interpretation of proverbs
  • math calculations
  • memorization, short-term recall
  • Identification of common objects
  • ability to follow multi-step commands
  • Ability to write or copy a simple drawing
  • CLOX screen
Self Awareness Issues
  • gather all information needed
  • judgement is 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-client relationshi and assessment process
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