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    Chapter 8 Assessment

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    Dennis James Bartolome
    The document discusses the purposes and process of conducting a psychosocial assessment. It outlines factors that influence the assessment and how to conduct an interview. The assessment should provide a comprehensive view of the client's emotional, mental, and behavioral state. It examines various areas like history, mood, thought processes, relationships, and more. The data is then analyzed to form nursing diagnoses and treatment plans. Psychological tests and the DSM diagnostic system are also reviewed. The assessment aims to effectively plan care while maintaining self-awareness and objectivity.

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    Chapter 8 Assessment

    Uploaded by

    Dennis James Bartolome
    274 views11 pages
    The document discusses the purposes and process of conducting a psychosocial assessment. It outlines factors that influence the assessment and how to conduct an interview. The assessment should provide a comprehensive view of the client's emotional, mental, and behavioral state. It examines various areas like history, mood, thought processes, relationships, and more. The data is then analyzed to form nursing diagnoses and treatment plans. Psychological tests and the DSM diagnostic system are also reviewed. The assessment aims to effectively plan care while maintaining self-awareness and objectivity.

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    22086009 Chapter 8 Assessment

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    The document discusses the purposes and process of conducting a psychosocial assessment. It outlines factors that influence the assessment and how to conduct an interview. The assessment should provide a comprehensive view of the client's emotional, mental, and behavioral state. It examines various areas like history, mood, thought processes, relationships, and more. The data is then analyzed to form nursing diagnoses and treatment plans. Psychological tests and the DSM diagnostic system are also reviewed. The assessment aims to effectively plan care while maintaining self-awareness and objectivity.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    274 views11 pages

    Chapter 8 Assessment

    Uploaded by

    Dennis James Bartolome
    The document discusses the purposes and process of conducting a psychosocial assessment. It outlines factors that influence the assessment and how to conduct an interview. The assessment should provide a comprehensive view of the client's emotional, mental, and behavioral state. It examines various areas like history, mood, thought processes, relationships, and more. The data is then analyzed to form nursing diagnoses and treatment plans. Psychological tests and the DSM diagnostic system are also reviewed. The assessment aims to effectively plan care while maintaining self-awareness and objectivity.

    Copyright:

    Attribution Non-Commercial (BY-NC)
    Download as PPT, PDF, TXT or read online from Scribd
    Download as ppt, pdf, or txt
    of 11

    Chapter 8 Assessment

    Purposes of Psychosocial Assessment

    To construct picture of clients 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 Clients health status Clients previous experiences/ misconceptions about health care Clients ability to understand Nurses attitude and approach

    How to Conduct the Interview Provide a comfortable, private, safe environment Obtain input from family and friends (with clients permission) Ask questions that are open-ended or closed-ended as needed

    Content of the Assessment


    History General appearance and motor behavior Mood and affect Thought process and content Assessment of suicide or harm toward others; if the client is having suicidal ideas, then assessment of lethality should follow

    Content of the Assessment


    Sensorium and intellectual processes Sensory-perceptual alterations Judgment and insight Self-concept 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 testscognitive abilities and intellectual functioning Personality testsself-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 clients 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

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