Chapter 8

Assessment
Purposes of Psychosocial Assessment
• To construct picture of client’s current
emotional state, mental capacity, and
behavioral function
• To form basis for plan
of care
• To establish clinical baseline
to evaluate effectiveness of
treatment and
interventions
Factors Influencing Assessment
• Client participation/feedback
• Client’s health status
• Client’s previous experiences/
misconceptions about health care
• Client’s ability to understand
• Nurse’s attitude and approach
How to Conduct the Interview

• Provide a comfortable, private, safe

environment
• Obtain input from family and friends
(with client’s permission)
• Ask questions that are open-ended or
closed-ended as needed
Content of the Assessment
• History
1.History of the client and family history
2.Age and developmental stage
3.Be sensitive with client’s cultural and
spiritual beliefs
4.Avoid stereotyping
• General appearance and motor behavior
1.dressing, hygiene and grooming
2.Assess for motor behavior
 Automatisms – repeated purposeless behavior often
indicative of anxiety
 Psychomotor retardation – overall slowed movement
 Waxy flexibility – maintenance of posture or position
over time
3.Assess speech for quantity, quality and
abnormalities.
 Neologisms
 Mood and affect
1. Affect is the outward expression of the client’s
emotional state
2. Mood refers to the client’s pervasive and enduring
emotional state
• Blunted affect – showing little or a slow to respond facial
expression
• Broad affect – displaying a full range of emotional
expression
• Restricted affect – displaying one type of expressions
usually serious or somber
• Flat affect – showing no facial expression
• Inappropriate affect – displaying a facial expression that
is incongruent with mood or situation
 MOOD
• Alexithymia - inability to identify and describe emotions
in the self
• Anhedonia is the inability to experience pleasure from
activities usually found enjoyable, e.g. exercise, hobbies,
singing, playing an instrument, sexual activities or social
interactions
• Apathy is a lack of feeling, emotion, interest, and
concern.
• Euphoria
 Thought process and content
• Thought process refers to how the client thinks
1.Circumstantial thinking – a client eventually answers a
question but only after giving excessive unnecessary
detail
2.Flight of ideas – excessive amount and rate of speech
composed of fragmented and unrelated ideas
3.Ideas of reference – client’s inaccurate interpretation that
general events are personally directed to him. Such as
hearing speech on the news believing that the message
has personal meaning
4.Loose association – disorganized thinking that jumps from
one idea to another with little or no evident relation
between the thoughts
5. Tangential thinking – wandering off the topic and never
providing the information requested
6. Word salad – flow of unconnected words that convey no
meaning to the listener
7. Thought blocking – stopping abruptly in the middle of a
sentence or train of thought
 CONTENT
1. Thought content is what the client actually says
• Delusions: Fixed, false beliefs firmly held in spite of
contradictory evidence
• Erotomanic: a person, usually of higher status, is in love
with the patient
• Grandiose: inflated sense of self-worth, power or wealth
• Somatic: patient has a physical defect
• Persecutory: others are trying to cause harm
 CONTENT
A. Delusion – a fixed false belief not based in reality
•Thought broadcasting – a delusional belief that others can
hear or know what the client is thinking
•Thought insertion – a delusional belief that others are
putting ideas or thought into the client’s head – that is, the
ideas or thoughts are not those of the client
•Thought withdrawal – a delusional belief that others are
taking the client’s thoughts away and the client is
powerless to stop it
B. Hallucination - is a perception in the absence of
external stimulus that has qualities of real perception
1. Auditory
2. Visual
3. Olfactory
4. Gustatory
5. Command
6. Tactile
• Assess for suicidal ideation
• Suicide assessment questions
1.Ideation – are you thinking about killing yourself
2.Plan – do you have plan to kill your self
3.Method– how do you plan to kill your self
4.Access – how would you carry out this plan
Content of the Assessment (cont’d)
• Sensorium and intellectual processes
– Orientation, memory, concentration, ability to think
abstractly
• Sensory-perceptual alterations
• Judgment and insight
• Self-concept – is the way one view oneself in terms of personal
worth and dignity
• Roles and relationships
• Physiologic and self-care concerns
Data Analysis
• Data analysis follows assessment
• Nursing diagnoses are formulated for
the nursing care plan
• The assessment data can be analyzed
to form an interdisciplinary treatment
plan or a plan for home care
Psychological Tests

Psychological tests are another source of

data to use in planning care.
• Intelligence tests—cognitive abilities
and intellectual functioning
• Personality tests—self-concept, impulse
control, reality testing, and major
defense mechanisms
Psychiatric Diagnoses

Based on the DSM-IV-TR multiaxial

system:
• Axis I: clinical disorders, other conditions that may
be a focus of clinical attention
• Axis II: personality disorders, mental retardation
• Axis III: general medical conditions
• Axis IV: psychosocial and environmental problems
• Axis V: Global Assessment of Functioning (GAF)
Mental Status Exam
Focuses on the client’s cognitive abilities:
• Orientation to person, time, place, date, season,
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
• Ability to write or copy a simple drawing
Self-Awareness Issues
• Self-awareness is important for the nurse so
that personal beliefs, attitudes, or feelings
do not interfere with the objective
assessment of clients
• It may be uncomfortable to discuss areas
such as suicidal ideas or sexuality issues,
but it is important for the nurse to do so
• Being open, clear, direct, and
nonjudgmental are essential nurse
behaviors; it may be helpful to discuss
feelings with a colleague if difficult issues
are encountered in the assessment process