GENERAL ASSESSMENT

CONSIDERATION
MODULE 3

PREPARED BY:
MARY RUTH V. ENRIQUEZ, RN MAN

General Assessment
considerations
1. Principles and Techniques of the
Psychiatric Nursing Interview
2. Mental Status Examination (MSE)
3. Diagnostic Examination Specific to
Psychiatric Patient

PRINCIPLES and TECHNIQUES OF

PSYCHIATRIC NURSING INTERVIEW

ASSESSMENT:

Is the first step of the nursing

process and involves the
collection , organization, and
analysis of information about the
clients health.

PSYCHOSOCIAL
ASSESSMENT:

Which includes a Mental Status Examination

Purposes of Psychosocial Assessment: is to
construct a picture of the clients current
Emotional state, Mental capacity, and
Behavioral function.
This assessment serves as the basis for
developing a plan of care to meet clients needs.
Clinical baseline used to evaluate the
effectiveness of treatment and interventions or a
measure of the clients progress.

FACTORS INFLUENCING
ASSESSMENT
1)
2)
3)

4)
5)

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

1)

2)
3)

4)

ENVIRONMENT
The nurse should conduct the psychosocial assessment in an
environment that is comfortable, private, and safe for both the
client and the nurse.
An environment that is fairly quiet with few distractions allows
the client to give his or her full attention to the interview.
Conducting the interview in a place such as a conference
room ensures the client that no one will overhear what is
being discussed.
The nurse should not choose an isolated location for
interview, particularly if the client is unknown to the nurse or
has a history of any threatening behavior.

INPUT FROM FAMILY AND FRIENDS

if family members, friends, or caregivers have

accompanied the client, the nurse should obtain their
perceptions of the clients behavior and emotional
state.
The nurse should then be aware that friends or family
may not feel comfortable talking about the client in his
or her presence and may provide limited information.
The client may not feel comfortable participating in the
assessment without family or friends.
This may limit the amount or type of information
the nurse obtains.

HOW TO PHRASE QUESTIONS

OPEN ENDED QUESTIONS : allows the

client to begin as he or she feels comfortable
and also gives the nurse an idea about the
clients perception of his or her situation.

Ex. Of an Open- ended questions:

What brings you here today?
Tell me what has been happening to you.
How can we help you?

CLOSED- 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.

Ex. Questions that can confuse to the client,

How are your eating and sleeping habits and have
you been taking any over- the counter
medications that affect your eating and sleeping?

Ex. Closed-Ended Questions:

How many hours did you sleep last night?
Have you been thinking about suicide?
How much alcohol have you been drinking?
How well have you been sleeping?
What over-the counter medications are you

taking?

The nurse should use a nonjudgmental tone

and language, particularly when asking about

sensitive information such as drugs or
alcohol use, sexual behavior, abuse or
violence, and childrearing practices.
Using nonjudgmental language and a matterof-fact tone avoids giving the client verbal
cues to become defensive or to not tell the
truth.
Ex. When asking a client about his or her
parenting role. The nurse should ask,
what types of discipline do you use? rather
than How often do you physically punish
your child?

 The first question is more likely to elicit

honest and accurate information; the

second question give wrong impression
that physical discipline is wrong, and it may
cause the client to respond dishonestly.

MENTAL STATUS
EXAMINATION

CONTENT OF THE ASSESSMENT:

History
General Appearance and Motor Behavior
Mood and Affect
Thought Process and Content
Sensorium and Intellectual Processes
Judgmental and Insight
Self-concept
Roles and Relationships
Physiologic and Self-care concerns

1. History

Includes: clients history, age and developmental stage,

cultural and spiritual beliefs, and beliefs about health
and illness.
The history of client , as well as his or her family, may
provide some insight on current situation.
Ex. Has the client experienced similar difficulties in the
past? Has the client been admitted to the hospital, and
if so, what was that experience like?
A family history that is positive for alcoholism, bipolar
disorder, or suicide is significant because it increases
the clients risk for these problems.

Age and developmental stage: are

important factors in the psychosocial
assessment. The nurse evaluates the clients
age and developmental level for congruence
with expected norms.

Ex. 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 are two of the
primary developmental tasks for adolescent.

If the client is 35 years old and still struggling

with these issues of self-identity and
independence, the nurse need to explore the
situation.
the clients age and developmental level
also may be incongruent with expected
norms if the client has a developmental
delay or mental retardation.

Cultural and Spiritual beliefs : the nurse must be

sensitive, avoid making inaccurate assumptions
about clients psychosocial functioning.
Many cultures have beliefs and values about a
persons role in society or acceptable social or
personal behavior differ from those of the nurses.
Ex. People from other cultures, such as Japan,
consider such as eye contact to be sign of
disrespects.
While Western cultures consider good eye
contact to be a positive characteristic
indicating self-esteem and paying attention.

2. GENERAL APPEARANCE AND MOTOR

BEHAVIOR

The nurse assesses the clients overall appearance,

including:
Hygiene and grooming
Appropriate dress
Posture
Eye contact
Unusual movements or mannerism
Speech (rate of the speech fast or slow,
responses a minimal yes or no without
elaboration, tone audible or loud)

Specific terms used in making assessments

of general appearance and motor behavior:
Automatisms: repeated purposeless behaviors
often indicative of anxiety, such as drumming
fingers, twisting locks of hair, or tapping the
foot.
Psychomotor retardation: overall slowed
movements
Waxy flexibility: maintenance of posture or
position over time even when it is awkward or
uncomfortable.
Neologism : invented words that have meaning
only for the client.

3. MOOD AND AFFECT

MOOD : refers to the clients pervasive and enduring
emotional state. EXPRESSED EMOTIONS
AFFECT : is the outward expression of the clients
emotional state. FACIAL EXPRESSION
The nurse assesses for consistency among the clients
mood, affect, and situation .
Ex. 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.

COMMON TERMS USED IN ASSESSING

AFFECT:

BLUNTED AFFECT: showing little or a slow-torespond facial expression.

BROAD AFFECT: displaying a full range of

emotional expression.

FLAT AFFECT: showing no facial expression.

INAPPROPRIATE AFFECT: displaying a facial
expression that is incongruent with mood or situation;
often silly or giddy regardless of circumstances.
RESTRICTED AFFECT: displaying one type of
expression, usually serious or somber.
MOOD
May be described as: happy, sad, depressed,
euphoric, anxious, or angry.
LABILE: when client exhibits unpredictable and rapid
mood swings from depressed and crying to euphoria
with no apparent stimuli.

4.THOUGHT PROCESS AND

CONTENT
Thought process: refers to how the client thinks.
The nurse can infer a clients thought process from speech
and speech patterns.
Thought Content: is what the client actually says.
The nurse assesses whether or not the clients
verbalizations make sense, that is, if ideas are related and
flow logically from one to the next.
The nurse also must determine whether the client seems
preoccupied, as if talking or paying attention to someone or
something else.
When the nurse encounters clients with marked difficulties
in thought process and content, the nurse may find it helpful
to ask focused questions requiring short answers.

COMMON TERMS RELATED TO THOUGHT

PROCESS AND CONTENT:
Circumstantial thinking: a client eventually answer
a question but only after giving excessive
unnecessary detail.
Delusion : a fixed false belief not based in reality.
Flight of ideas : excessive amount and rate of
speech composed of fragmented or unrelated ideas.
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 had personal meaning.

Loose associations: disorganized thinking that jumps from one

idea to another with little or no evident relation between the
thoughts.
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 unable to continue the idea.
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 thoughts into the clients head- that is, the idea are not
those of the client.
Thought withdrawal: a delusional belief that others are taking
the clients thoughts away and the client is powerless to stop it.
Word salad: flow of unconnected words that convey no meaning
to the listener.

Assessment of suicide or Harm

toward others

The nurse must determine whether the depressed

or hopeless client has suicidal ideation or lethal
plan.
The nurse does so by asking the client directly Do
you have thoughts of suicide? or what thoughts
of suicide have you had?
If the client is angry, hostile, or making threatening
remarks about a family member, spouse, or
anyone else, the nurse must ask if the client has
thoughts or plans about hurting that person.

The nurse does so by questioning the client

directly:
What thoughts have you had about hurting
(persons name)?
What is your plan?
What do you want to do to (persons name)?
When a client makes specific threats or has a
plan to harm another person, health providers
are legally obliged to warn the person who
is the target of the threats or plan.
Duty to warn: legal term used.

5. SENSORIUM AND
INTELLECTUAL PROCESSES
ORIENTATION
MEMORY
ABILITY TO CONCENTRATE
ABSTRACT THINKING & INTELLECTUAL
ABILITIES
ORIENTATION:
Refers to the clients 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 documented as:

Oriented x 3 : oriented
Oriented x1 : disoriented (person only)
Oriented x2 : disoriented (person and place)
When a person is disoriented: first loses track
of time, then place, and finally person.
Orientation returns in reverse order: person,
place, time

MEMORY:
The nurse directly assesses memory, both
recent and remote by asking questions with
verifiable answers.
Ex.
What is the name of the current president?
Who was the president before that?
In what country do you live?
What is the capital of this state?
What is your social security number?
Verifiable answers : give accurate answers.

ABILITY TO CONCENTRATE:
The nurse assesses the clients ability to concentrate by
asking the client to perform certain tasks:
Spell the word WORLD backward: DLROW
Serial 7: begin with 100 subtract 7, subtract 7, again
and so on.
Repeat the days of the week backward: Sunday,
Saturday, Friday, Thursday, Wednesday, Tuesday,
Monday .
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. ( The nurse should give the instructions at
one time)

ABSTRACT THINKING AND INTELLECTUAL

ABILITIES:
When assessing the intellectual functioning,
the nurse must consider the clients level of
formal education. Lack of formal education
could hinder performance in many tasks in this
section.
The nurse assesses the clients ability to use
ABSTRACT THINKING, which is associations
or interpretations about a situation or
comment.

The nurse ask the client to interpret a common

proverb. If the client can explain the proverb
correctly, his or her abstract thinking
abilities are intact. If the client provides a
literal explanation of the proverb and cannot
interpret its meaning, abstract thinking
abilities are lacking.
When the client continually gives literal
translations, this is evidence of concrete
thinking.

Ex.
Proverb : A STITCH IN TIME SAVES TIME
ABSTRACT meaning: If you take the time to
fix something now, youll avoid bigger
problems in the future.
LITERAL translation: Dont forget to sew up
holes in your clothes (Concrete thinking)

SENSORY- PERCEPTUAL ALTERATIONS

Some clients experience HALLUCINATIONS (false

sensory perceptions or perceptual experiences that do
not really exist),
Hallucinations = can involve the five senses and bodily
sensations.
Auditory hallucination: hearing voices, are the most
common
Visual hallucination = seeing things dont really exist,
are second most common.
Clients perceive hallucinations as real experiences,
but later in the illness, they may recognize the as
hallucination.

6. JUDGMENT AND
INSIGHT

JUDGMENT: refers to ability to interpret ones

environment and situation correctly and adapt
ones behavior and decisions accordingly.
Problems with judgment may be evidenced as
the client describes recent behavior and
activities that reflect a lack of reasonable care
for self or others.
Ex. The client may spent large sums of money
on frivolous items when he or she cannot afford
basic necessities such as food or clothings.

INSIGHT : is the ability to understand the true

nature of ones situation and accept some personal
responsibility for that situation.
The nurse frequently can infer insight from the
clients ability to describe realistically the strengths
and weaknesses of his or her behavior.
Ex. Poor insight : a client who places all blame on
others for his own behavior, saying its y wifes
fault that i drink and get into fights, because she
nags me all the time.
This client is not accepting responsibility for his
drinking and fighting.

SELF- CONCEPT

Is the way one views oneself in terms of

personal worth and dignity.
To assess clients self-concept, the nurse can
ask the client to describe himself or herself and
what characteristics he or she likes and what
he or she would change.
Description of self in term of Physical
characteristics gives the nurse information
about the clients body image.

Emotions that client frequent experiences,

such as sadness or anger, and whether or not
the client is comfortable with those emotions.
The nurse also must assess the clients coping
strategies.
Ex. Questions : What do you do when you
have a problem? How do you solve it?

ROLES AND RELATIONSHIP

People functioning in their community

through various roles such as mother, wife,
son, daughter, teacher, secretary, or
volunteer.
The nurse assesses the roles the client
occupies, client satisfaction with those roles,
and whether the client believes he or she is
fulfilling the roles adequately.

Relationships with other people are important

to ones social and emotional health.
Relationships vary in terms of significance,
level of intimacy or closeness, and intensity.
The inability to sustain satisfying relationships
can result from mental health problems or can
contribute to the worsening of some problems.
The nurse must assess the relationships in the
clients life, the clients satisfaction with those
relationships, or any loss of relationship.

Common questions:
Do you feel close to your family?
Do you have or want a relationship with a
significant other?
Are your relationships meeting your needs for
companionship or intimacy?
Can you meet your sexual needs satisfactorily?
Have you been involved in any abusive
relationship?

PHYSIOLOGIC AND SELF-CARE CONSIDERATION

When doing psychosocial assessment, the nurse

must include physiologic functioning. Although a
full physical health assessment may not be
indicated, emotional problems often affect some
areas of physiologic function.
Emotional problems can greatly affect eating and
sleeping patterns: under stress, people may eat
excessively 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.

SELF CARE CONSIDERATION:

The nurse also ask the client if he or she has
any major or chronic health problems and if he
or she takes prescribed medications as
ordered and follows dietary recommendations.
Noncompliance with prescribed medication is
an important area. The nurse must help the
client feel comfortable enough to reveal this
information.

DIAGNOSTIC PROCEDURE SPEIFIC

TO PSYCHIATRIC PATIENTS

Assignment:

Know the Diagnostic examination specific to

psychiatric patients.
Assess one client/ patient in the area using the
MSE.
Submission: NEXT MEETING, in a long bond
paper, computerized.
No duplications of assignment , minus
points