Ch.

8: Assessment

Key terms:
Abstract thinking: ability to make associations or interpretations about a situation or comment
Affect: the outward expression of the clients emotional state
Automatisms: repeated, seemingly purposeless behaviors often indicative of anxiety, such as
drumming fingers, twisting locks of hair, or tapping the foot; unconscious mannerism.
Blunted affect: showing little or a slow-to-respond facial expression; few observable facial expressions
Broad affect: displaying a full range of emotional expressions
Circumstantial thinking: term used when a client eventually answers a question but only after giving
excessive, unnecessary detail
Concrete thinking: when the client continually gives literal translations; abstraction is diminished or
absent
Delusion: a fixed, false belief not based in reality
Duty to warn: the exception to the clients right to confidentiality; when healthcare providers are legally
obligated to warn another person who is the target of the threats or plan by the client, even if the threats
were discussed during therapy sessions otherwise protected by confidentiality.
Flat affect: showing no facial expression
Flight of ideas: excessive amount and rate of speech composed of fragmented or unrelated ideas;
racing, often unconnected, thoughts
Hallucinations: false sensory perceptions or perceptual experiences that do not really exist.
Ideas of reference: clients inaccurate interpretation that general events are personally directed to him
or her, such as hearing a speech on the news and believing the message has personal meaning
Inappropriate affect: displaying a facial expression that is incongruent with mood or situation; often silly
of giddy regardless of circumstances
Insight: the ability to understand the true nature of ones situation and accept some personal
responsibility for that situation.
Judgment: refers to the ability to interpret ones environment and situation correctly and to adapt ones
behavior and decisions accordingly.
Labile: rapidly changing or fluctuating, such as someones mood or emotions
Loose associations: disorganized thinking that jumps from one idea to another with little or no evident
relation between the thoughts
Mood: refers to the clients pervasive and enduring emotional state
Neologisms: invented words that have meaning only for the client
Psychomotor retardation: overall slowed movements; a general slowing of all movements; slow
cognitive processing and slow verbal interaction
Restricted affect: displaying one type of emotional expression, usually serious or somber
Self-concept: the way one views oneself in terms of personal worth and dignity
Tangential thinking: wandering off the topic and never providing the information requested
Thought blocking: stopping abruptly in the middle of a sentence or train of thought; sometimes client is
unable to continue the idea
Thought broadcasting: a delusional belief that others can hear or know what the client is thinking
Thought content: what the client actually says

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Ch. 8: Assessment

Thought insertion: a delusional belief that others are putting ideas or thoughts into the clients head;
that is, the ideas are not those of the client
Thought process: how the client thinks
Thought withdrawal: a delusional belief that others are taking the clients thoughts away and the client
is powerless to stop it
Waxy flexibility: maintenance of posture or position over time even when it is awkward or uncomfortable
Word salad: flow of unconnected words that convey no meaning to the listener

Objectives:
1. Identify the categories used to assess the clients mental health status.
a. History
i. Age
ii. Developmental stage
iii. Cultural considerations
iv. Spiritual beliefs
v. Previous history
b. General Appearance and Motor Behavior
i. Hygiene and grooming
ii. Appropriate dress
iii. Posture
iv. Eye contact
v. Unusual movements or mannerisms
vi. Speech
c. Mood and Affect
i. Expressed emotions
ii. Facial expressions
d. Thought process and content
i. Content (what client is thinking)
ii. Process (how client is thinking)
iii. Clarity of ideas
iv. Self-harm or suicide urges
e. Sensorium and Intellectual processes
i. Orientation
ii. Confusion
iii. Memory
f. Abnormal Sensory experiences or misperceptions
i. Concentration
ii. Abstract thinking abilities
g. Judgment and Insight
i. Judgment (interpretation of environment)
ii. Decision-making ability
iii. Insight (understanding ones own part in current situation)
h. Self-concept
i. Personal view of self
ii. Description of physical self
iii. Personal qualities or attributes
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Ch. 8: Assessment

i. Roles and Relationships

i. Current roles
ii. Satisfaction with roles
iii. Success at roles
iv. Significant relationships
v. Support systems
j. Physiologic and Self-care considerations
i. Eating habits
ii. Sleep patterns
iii. Health problems
iv. Compliance with prescribed medications
v. Ability to perform activities of daily living

2. Formulate questions to obtain information in each category.

a. General appearance and motor behavior: Is the client dressed appropriately for age and
weather?
b. Mood and affect: Is the clients mood consistent with the situation? On a scale of 1-10, with 1
being the least depressed, and 10 being most depressed, where would you place yourself right
now?
c. Thought process and content: Do the clients verbalizations make sense? Is the client
wandering off topic?
d. Sensorium and Intellectual processes: What is your name? Where are you right now? Do you
know who is the current US president? Repeat the days of the week backwards.
e. Abnormal Sensory experiences or misperceptions: What is similar about an apple and an
orange? What do the newspaper and the television have in common?
f. Judgment and Insight: What would you do if you found a stamped addressed envelope on the
ground? Does your drinking affect your work or home life?
g. Self-concept: What do you do when you have a problem? How do you solve it? What usually
works to deal with anger or disappointment?
h. Roles and Relationships: Do you feel close to your family? Do you have or want a relationship
with a significant other?
i. Physiologic and self-care considerations: Do you have any major or chronic health conditions
that require you to take medications with dietary restrictions? Do you use alcohol and over-the-
counter or illicit drugs? Are you taking your medications as prescribed?

3. Describe the clients functioning in terms of self-concept, roles, and relationships.

a. Self-concept: The client should be able to describe themselves and what characteristics they
like about themselves, and what, if anything, would they change about themselves. They should
be able to describe their body image, the emotions they frequently experience, and whether
theyre comfortable with these emotions or not. They should be able to describe their coping
strategies.
b. Roles & relationships: Clients should be able to describe their role in their community (mother,
father, daughter, sister, secretary, volunteer, etc.). Is this role fulfilling for them? Clients
relationships should be satisfying. The inability to maintain satisfying relationships can result
from mental health problems, or can contribute to worsening of some problems. Clients family
functioning should entail their parenting practices, patterns of social interaction among family
members, patterns of problem solving and decision-making, relationships with extended family,
and health behaviors such as mental or physical illness, disabilities, alcohol and drug use

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Ch. 8: Assessment

4. Recognize key physiologic functions that are frequently impaired in people with mental
disorders.
a. For example, emotional problems can affect eating and sleeping patterns: under stress, people
may overeat or not at all and may sleep up to 20 hours a day or may be unable to sleep more
than 2 or 3 hours a night.
b. Clients may not be taking their prescribed medications as ordered, or follow the dietary
recommendations.
c. Clients may use alcohol and over-the-counter medications or illicit drugs.

5. Obtain and organize psychosocial assessment data to use as a basis for planning nursing care.
a. Data analysis involves thinking about the overall assessment rather than focusing on isolated
bits of information. Look for patterns or themes in the data that lead to conclusions about the
clients strengths and needs and to a particular nursing diagnosis. The data analysis leads to
the formulation of nursing diagnoses as a basis for the clients plan of care. The nurse must also
articulate the clients needs in ways that are clear to health team members in other disciplines
as well as to families and caregivers. The nurse must describe and document the goals and
interventions that many others, not just professional nurses, can understand.

6. Examine ones own feelings and any discomfort discussing suicide, homicide, or self-harm
behaviors with a client.
a. Self-awareness is crucial when trying to obtain accurate and complete information from the
client during the assessment process. Be aware of your own feelings, biases, and values that
could interfere with the psychosocial assessment of a client with different beliefs, values, and
behaviors. The nurse shouldnt make judgments about the clients practices. Be able to listen to
the client and support the discussion of personal topics, this requires practice and gets easier
with experience. Talking with coworkers about such discomfort and methods to alleviate it often
helps. Some beginning nurses feel uncomfortable assess the client for suicidal thoughts, or
believe that asking about suicide might suggest it to a client who had not previously thought
about it. Its been shown that the safest way to assess a client with suspected mental disorders
is to ask him or her clearly and directly about suicidal ideas. Its the nurses professional
responsibility to keep the clients safety needs first and foremost.

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