communications ch. 8 assessment

thought process/ content: delusion

a fixed false belief not based in reality

thought process/ content: ideas of references

client's inaccurate interpretation that general events are personally directed to him or her, such as hearing a speech on the news and believing the message had personal meaning

thought process/ content: tangential thinking

wandering off the topic and never providing the information requested

mood

refers to the client's pervasive and enduring emotional state.

the interview: environment

-Comfortable, private, safe for both the client and the nurse -Environment that is fairly quiet with few distractions allows the client to give his or her full attention to the interview. -Quiet with few distractions

the interview: input fro family, friends

-Information about their perceptions of client -Information may be limited by certain factors. -It is desirable to conduct at least part of the assessment without others, especially in cases of suspected abuse or intimidation.

assessment content

The nurse should use some kind of organizing framework so that he or she can assess the client in a thorough and systematic way that lends itself to analysis and serves as a basis for the client's care.

clients pervious experiences/ misconceptions about health care

client's perception of his or her circumstances can elicit emotions that interfere with obtaining an accurate psychosocial assessment. -Ex: If the client is reluctant to seek treatment or has had previous unsatisfactory experiences with the health care system, he or she may have difficulty answering questions directly. The client may minimize or maximize symptoms or problems or may refuse to provide information in some areas. -The nurse must address the client's feelings and perceptions to establish a trusting working relationship before proceeding with the assessment.

sensorium/ intellectual processes: memory

directly assesses memory, both recent and remote, by asking questions with verifiable answers

thought process/ content: loose associations

disorganized thinking that jumps from one idea to another with little or no evident relation between the thoughts

common terms in assessing affect: inappropriate

displaying a facial expression that is incongruent with mood or situation; often silly or giddy regardless of circumstances

common terms in assessing affect: broad

displaying a full range of emotional expressions

common terms in assessing affect: restricted

displaying one type of expression, usually serious or somber

true/false Personality tests measure a person's cognitive abilities.

fasle -Personality tests reflect the client's personality in areas such as self-concept, impulse control, reality testing, and major defenses.

true/false vWhen interviewing a client, the nurse should select an area that is quiet and isolated from others.

fasle -the nurse should interview a client in an environment that is comfortable, private, and safe for both the client and the nurse.

thought process

how the client thinks

mental status examination

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 perform 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.

personality tests

reflect the client's personality in areas such as self-concept, impulse control, reality testing, and major defenses. -Self-concept, impulse control, reality testing, major defenses -Objective -Projective: 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 vary widely.

self awareness issues

-The nurse must be aware of any feelings, biases, and values that could interfere with the psychosocial assessment of a client with different beliefs, values, and behaviors. -Gather all information needed (Judgments are 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) -Personal topics takes practice and usually gets easier with experience. -Do not allow personal beliefs to interfere with nurse-client relationship and assessment process.

appearance/ motor behavior

The nurse assesses the client's overall appearance, including dress, hygiene, and grooming. -Hygiene/grooming -Appropriate dress -Posture -Eye contact -The nurse also observes the client's posture, eye contact, facial expression, and any unusual tics or tremors. -Unusual movements/mannerisms

roles and relationships: ability to fulfill roles

The ability to fulfill a role or the lack of a desired role is often central to the client's psychosocial functioning.

history: cultural considerations

Western cultures generally expect that as a person reaches adulthood, he or she becomes financially independent, leaves home, and makes his or her own life decisions. In contrast, in some Eastern cultures, three generations may live in one household, and elders of the family make major life decisions for all

history: age

a client may be struggling with personal identity and attempting to achieve independence from his or her parents. If the client is 17 years old, these struggles are normal and anticipated because these are two of the primary developmental tasks for the adolescent. If the client is 35 years old and still struggling with issues of self-identity and independence, the nurse will need to explore the situation.

thought process/ content: thought insertion

a delusional belief that others are putting ideas or thoughts into the client's head—that is, the ideas are not those of the client

vWhich of the following would the nurse include when assessing a client's self-concept?

body image -Assessment of the client's self-concept includes information about the client's personal view of self, a description of physical self, and his or her emotions.

history: spiritual beliefs

evil eye

thought process/ content: thought blocking

stopping abruptly in the middle of a sentence or train of thought; sometimes unable to continue the idea

assess for consistency

the client may have an angry facial expression but deny feeling angry or upset in any way. Or, the client may be talking about the recent loss of a family member while laughing and smiling.

roles and relationships: current roles

People function in their communities through various roles such as mother, wife, son, daughter, teacher, secretary, or volunteer.

if the clients reports being depressed, the nurse might ask

"On a scale of 1 to 10, with 1 being least depressed and 10 being most depressed, where would you place yourself right now?"

clients health status

client's health status can also affect the psychosocial assessment. -Ex: If the client is anxious, tired, or in pain, the nurse may have difficulty eliciting the client's full participation in the assessment. The information that the nurse obtains may reflect the client's pain or anxiety rather than an accurate assessment of the client's situation. -The client may need to rest, receive medications to alleviate pain, or be calmed before the assessment can continue.

sensory perceptual alterations

hallucinations (false sensory perceptions or perceptual experiences that do not really exist). Hallucinations can involve the five senses and bodily sensations. Auditory hallucinations (hearing voices) are the most common; visual hallucinations (seeing things that don't really exist) are the second most common. Initially, clients perceive hallucinations as real experiences, but later in the illness, they may recognize them as hallucinations.

what may the clients moos be described as?

happy, sad, depressed, euphoric, anxious, or angry. When the client exhibits unpredictable and rapid mood swings from depressed and crying to euphoria with no apparent stimuli, the mood is called labile (rapidly changing)

waxy flexibility

maintenance of posture or position over time even when it is awkward or uncomfortable

nurses attitude and approach

nurse's attitude and approach can influence the psychosocial assessment. -Ex: if the client perceives the nurse's questions to be short and curt or feels rushed or pressured to complete the assessment, he or she may provide only superficial information or omit discussing problems in some areas altogether. The client may also refrain from providing sensitive information if he or she perceives the nurse as nonaccepting, defensive, or judgmental. -Ex: a client may be reluctant to relate instances of child abuse or domestic violence if the nurse seems uncomfortable or nonaccepting. -The nurse must be aware of his or her own feelings and responses and approach the assessment matter-of-factly.

automatisms

repeated purposeless behaviors often indicative of anxiety, such as drumming fingers, twisting locks of hair, or tapping the foot

common terms in assessing affect: blunted

showing little or a slow-to-respond facial expression

common term in assessing affect: flat

showing no facial expression

client participation/ feedback

A thorough and complete psychosocial assessment requires active client participation. -Ex: a client who is extremely depressed may not have the energy to answer questions or complete the assessment. -Clients exhibiting psychotic thought processes or impaired cognition may have an insufficient attention span or may be unable to comprehend the questions being asked.

what is the purpose of the psychosocial assessment?

-Picture of client's current emotional state, mental capacity, behavioral function -Basis for developing plan of care -Clinical baseline to evaluate effectiveness of treatment or measure client's progress

roles and relationships: satisfaction with relationships

Relationships with other people are important to one's social and emotional health. Inability to sustain satisfying relationships can result from mental health problems or can contribute to the worsening of some problems.

ongoing, dynamic process

The nurse will assess and reassess throughout the care of the client. Reassessment is the basis for changing the plan of care, evaluation of treatment effectiveness, discharge planning, and follow-up care in the community.

judgement and insight

-refers to the ability to interpret one's environment and situation correctly and to adapt one's behavior and decisions accordingly. -The nurse may ask hypothetical questions, such as "If you found a stamped addressed envelope on the ground, what would you do?"

psychological tests

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, impulse control, reality testing, and major defenses.

thought process/ content: circumstantial thinking

a client eventually answers a question but only after giving excessive unnecessary detail

intelligence tests

are designed to evaluate the client's cognitive abilities and intellectual functioning. -Cognitive abilities -Intellectual functioning

what are both intelligence tests and personality tests frequently criticized as?

as being culturally biased

thought process/ content: flight of ideas

excessive amount and rate of speech composed of fragmented or unrelated ideas

thought process/ content: word salad

flow of unconnected words that convey no meaning to the listener

affect

is the outward expression of the client's emotional state.

speech

neologisms: invented words that have meaning only for the client

psychomotor

overall slowed movements

overall assessment

thinking about the overall assessment rather than focusing on isolated bits of information. -Not isolated bits of information -Patterns or themes in data → conclusions about clients' strengths and needs, nursing diagnoses such as chronic low self-esteem or ineffective coping.

assessment of suicide of harm toward others

-The nurse must determine whether the depressed or hopeless client has suicidal ideation or a lethal plan. -Anger, hostility, or threats toward another person the nurse must ask whether the client has thoughts or plans about hurting that person

thought process\ content: thought withdrawal

a delusional belief that others are taking the client's thoughts away and the client is powerless to stop it

assessment

is the first step of the nursing process and involves the collection, organization, and analysis of information about the client's health

clients ability to understand

the nurse must also determine the client's ability to hear, read, and understand the language being used in the assessment. -Ex: if the client's primary language differs from that of the nurse, the client may misunderstand or misinterpret what the nurse is asking, which results in inaccurate information. A client with impaired hearing may also fail to understand what the nurse is asking. -It is important that the information in the assessment reflects the client's health status; it should not be a result of poor communication.

content

what the client says

diagnostic and statistical manual of mental disorders

-Classifies mental disorders into categories -Describes each disorder -Provides diagnostic criteria for each disorder

Specific threats or plans to harm someone

-Health care providers are legally obligated to warn the person who is the target of the threats or plan. -The legal term for this is duty to warn. -This is one situation in which the nurse must breach the client's confidentiality to protect the threatened person.

the interview: questions

-Open-ended to initiate assessment -Doing so allows the client to begin as he or she feels comfortable and also gives the nurse an idea about the client's perception of his or her situation. -If the client cannot organize his or her thoughts or has difficulty answering open-ended questions, the nurse may need to use more direct questions to obtain information. -Questions need to be clear, simple, and focused on one specific behavior or symptom; they should not cause the client to remember several things at once

clients 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

categories of family assessment

-Parenting practices, such as methods of discipline, supervision of children, rules -Patterns of social interaction among family members, expression of feelings -Patterns of problem-solving and decision-making -Problems related to housing, finances, transportation, child care -Relationships with extended family members -Health behaviors such as mental or physical illness, disabilities, alcohol and drug use

sensorium/ intellectual processes: ability to concentrate

-asking the client to perform certain tasks: -Spell the word "world" backward. -Begin with the number 100, subtract 7, subtract 7 again, and so on. This is called "serial sevens." -Repeat the days of the week backward. -Perform a three-part task, such as "Take a piece of paper in your right hand, fold it in half, and put it on the floor."

self concept

-is the way one views oneself in terms of personal worth and dignity. -Personal worth and dignity -The nurse can ask the client to describe him or herself, what characteristics he or she likes, and what he or she would change. -Description of physical characteristics/body image -Emotions the client frequently experiences, such as sadness or anger and whether the client is comfortable with those emotions.

sensorium/ intellectual processes: orientation

-refers to the client's recognition of person, place, and time—that is, knowing who and where he or she is and the correct day, date, and year. This is often documented as "oriented × 3." -Absence of correct information about person, place, and time is referred to as disorientation, or "oriented × 1" (person only) or "oriented × 2" (person and place).

psychiatric diagnoses

Medical diagnoses of psychiatric illness are found in the Diagnostic and Statistical Manual of Mental Disorders (DSM-5). It describes each disorder and provides diagnostic criteria to distinguish one from another.

online activity/ social media

Online activity such as Facebook and Skype can sometimes enhance real-life relationships.

history: previous history

Some people view emotional or mental problems as family concerns to be handled only among family members. They may view seeking outside or professional help as a sign of individual weakness. Others may believe that their problems can be solved only with the right medication, and they will not accept other forms of therapy

thought process/ content: thought broadcasting

a delusional belief that others can hear or know what the client is thinking

history: development stage

developmental level may also be incongruent with expected norms if the client has a developmental delay or intellectual disability

insight

- is the ability to understand the true nature of one's situation and accept some personal responsibility for that situation. -Client states "It's my wife's fault that I drink and get into fights, because she nags me all the time." This client is not accepting responsibility for his or her drinking and fighting.

sensorium/ intellectual processes: abstract thinking and intellectual abilities

- to make associations or interpretations about a situation or comment. -Ex: Proverb: A stitch in time saves nine. -Abstract meaning: If you take the time to fix something now, you'll avoid bigger problems in the future.

physiological and self care considerations

-Emotional problems can greatly affect eating and sleeping patterns Eating habits: under stress, people may eat excessively or not at all. -Sleep patterns: may sleep up to 20 hours a day or be unable to sleep more than 2 or 3 hours a night. -Clients with bipolar disorder may not eat or sleep for days. -Clients with major depression may not be able to get out of bed. -Major or chronic health problems: he or she takes prescribed medications as ordered and follows dietary recommendations. -Use of drugs and/or alcohol -Noncompliance with prescribed medications: explore the barriers to compliance.

psychosocial assessment

includes a mental status examination

roles and relationships: changes in roles

Changes in roles may also be part of the client's difficulty.