NCM-117-SKILLS LAB-WEEK 4-PSYCHOSOCIAL ASSESSMENT23-STUD.pdf

NCM 117 SKILLS LAB
WEEK 4
VIDEBECK: CHAPTER 8

After reading this chapter, you should be able to:
1. Identify the categories used to assess the client’s mental health
status.
2. Formulate questions to obtain information in each category.
3. Describe the client’s functioning in terms of self-concept, roles,
and relationships.
4. Recognize key physiologic functions that are frequently impaired
in people with mental disorders.
5. Obtain and organize psychosocial assessment data to use as a
basis for planning nursing care.

includes a mental status examination.
PURPOSE : to construct a picture of the client’s current emotional
state, mental capacity, and behavioral function.
This assessment serves as the basis for developing a plan of care
to meet the client’s needs.
The assessment is also a clinical baseline used to evaluate the
effectiveness of treatment and interventions or a measure of the
client’s progress (American Nurses Association, 2014).

- an organized approach to collecting data
about a person’s psychosocial function. The
mental status assessment is very broad in
scope, so this section focuses on cognitive
abilities, and other aspects of psychosocial
function
Mental Status Assessment

The framework for psychosocial assessment discussed here and used
throughout this textbook contains the following components:
• History
• General appearance and motor behavior
• Mood and affect
• Thought process and content
• Sensorium and intellectual processes
• Judgment and insight
• Self-concept
• Roles and relationships
• Physiologic and self-care concerns

• Age
• Developmental stage
• Cultural considerations
• Spiritual beliefs
• Previous history
The history of the client, as well as his or her family, may provide some insight into the
client’s current situation. For example, 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 client’s risk for these problems

• Hygiene and grooming
• Appropriate dress
• Posture
• Eye contact
• Unusual movements or mannerisms
• Speech

Physical Appearance
 readily observed and reveals many aspects of
psychosocial function.
 Clothing, grooming, cosmetics, and hygiene provide
many clues to psychological function, but they are
only clues, and questions must be asked before any
conclusions are drawn.
 Observations about how clothing fits provide clues to
weight changes (e.g., if clothing is too tight or loose,
particularly in the waist).
Psychosocial Assessment Components

Physical Appearance
 A history of weight loss may provide clues to
depression, cognitive impairment, medical
status, or other barriers to adequate nutrition
Observations about grooming practices, such
as a woman’s hair being dyed, can suggest
any of the following questions about
psychosocial function: Is this a reflection of
positive or negative self-esteem?

Specific terms used in making assessments of general
appearance and motor behavior include the following:
• 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

Motor Function and Psychomotor Behaviors
 includes posture, movement, and body language, can provide
clues to broader aspects of psychosocial function.
For example:
 stooped posture may be a clue to depression, whereas erect
 posture may indicate positive self-esteem.
 A shuffling, staggering, or uncoordinated gait could indicate
neurologic deficits secondary to a disease process or adverse
effects from alcohol or medications.
 Gait disturbances, as well as other abnormal movements, are
 possible signs of tardive dyskinesia or extrapyramidal symptoms.

The nurse assesses the client’s speech for quantity, quality, and any
abnormalities.
 Does the client talk nonstop?
 Does the client perseverate (seem to be stuck on one topic and
unable to move to another idea)?
 Are responses a minimal “yes” or “no” without elaboration?
 Is the content of the client’s speech relevant to the question being
asked? Is the rate of speech fast or slow?
 Is the tone audible or loud?
 Does the client speak in a rhyming manner?
 Does the client use neologisms (invented words that have
meaning only for the client)?
The nurse notes any speech difficulties such as stuttering or lisping.

, “Well, hell, it’s well to
tell.”
How are you
feeling David?
Clang association
association of words based
upon sound rather than
concepts

I am here from a foreign university . . . and you have to have a ‘plausity’ of all
acts of amendment to go through for the children’s code . . . it is an
‘amorition’ law . . . the children have to have this ‘accentuative’ law so they
don’t go into the ‘mortite’ law of the church”
Neologism
a new word that is coined especially by a
person affected with schizophrenia and is
meaningless except to the coiner,

• Expressed emotions
• Facial expressions
Mood refers to the client’s pervasive and
enduring emotional state.
Affect is the outward expression of the client’s
emotional state.

Common terms used in assessing affect include the following:
• Blunted affect: showing little or a slow-to-respond facial
expression
• Broad affect: displaying a full range of emotional expressions
• 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

Note: The client’s mood may 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).

• Content (what client is thinking)
• Process (how client is thinking)
• Clarity of ideas
• Self-harm or suicide urges
Thought process refers to how the client thinks. The nurse
can infer a client’s thought process from speech and speech
patterns.
Thought content is what the client actually says.

4. Thought Process and content
Thought process is how the client thinks
Nurse can infer client’s thought process from speech and speech
patterns.
Thought content what the client actually says
Nurse assesses whether or not the client’s verbalization makes sense
Note: ask focused questions requiring short answers
Clarity of Ideas
Self-harm or suicide urges

Ability to concentrate and Think abstractly
Ability to concentrate – the nurse assesses the client’s ability to
concentrate by asking the client to perform certain task such as:
Spell the word WORLD backward
Serial sevens – begin with the #100, subtract 7, subtract 7
again and so on.
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.”

Common terms related to the assessment of thought process and content
include the following:
 Flight of ideas: excessive amount and rate of speech composed of
fragmented or unrelated ideas
 Loose associations: disorganized thinking that jumps from one idea to another
with little or no evident relation between the thoughts
 Circumstantial thinking: a client eventually answers a question but only after
giving excessive unnecessary detail
 Tangential thinking: wandering off the topic and never providing the information
requested
 Word salad: flow of unconnected words that convey no meaning to the
listener

Yes, he died. He was sick, and now he’s gone.
He likes to fish with me, down at the river.
He’s going to take me hunting. I have guns. I
can shoot you and you’d be dead in a minute.
I was sorry to hear that
your Uncle Bill died a few
years ago. How are you
feeling about him these
days?
Loose Association /Derailment
abrupt shifting of thoughts or associations
so that they do not follow one another in a
logical sequence.

I accidents can inevitably happen. Just like
vehicular accidents. In fact an MMDA study
reveals that 4 in every 100,000 Filipinos died due
to road crashes in Metro Manila in year 2017. My
brother died when he was just 17.
Can you tell me how
old was your brother
when he passed
away?
Circumstantiality
"non-linear thought pattern" and
occurs when the focus of a
conversation drifts, but often comes
back to the point.

I really don’t want to be here. I’ve
got other things to do. The time is
right, and you know, when
opportunity knocks . .
Why are you here
in the hospital,
David?
Tangentiality
going off on a tangent
instead of answering a specific
question.

“Popping bananas and zebra tries
storing four selling in dancing
cars.”
How are you
feeling David?
Word Salad
confused or unintelligible
mixture of seemingly
random words and phrases"

Common terms related to the assessment of thought process and content
include the following:
 Delusion: a fixed false belief not based in reality
 Ideas of reference: 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 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 client’s head—that is, the ideas 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

Well, I love sports. I really enjoy playing
badminton and ball games such as basketball and
volley…….
Can you tell me about
your favorite hobby?
Thought Blocking
a person stops speaking suddenly and
without explanation in the middle of
a sentence

Boston.
Where were you
born?
Perseveration
the repetition of a particular response (such
as a word, phrase, or gesture) in in in
response to a stimulus
"Can you say the days
of the week
backward?"
Boston.

"I've been working in New York for 20
years, 20 years, 20 years, ...
Verbigeration
obsessive repetition of random words in
without a stimulus

Can you tell me about your hobbies?
Echolalia
the precise repetition, or echoing, of words
and sounds heard.
Can you tell me about
your hobbies?

• Orientation
• Confusion
• Memory

5. Sensorium and Intellectual processes
Orientation- clients recognition of person, place, time, correct day, date,
year
“oriented x 3” – oriented to 3 spheres
4th sphere – situation
Disorientation- absence of correct information to about person, place
and time
“oriented x 1” –oriented to person only
“oriented x 2” –oriented to person and place
Disorientation – absence of correct information about person, place, and
time; or “orientation x 1” (person only) or “oriented x2” (person and
place)

Orientation
 Orientation to person, place, and time is the indicator of mental status
that is most frequently assessed and documented.
For example the following questions are the gold standard for assessing
orientation:
“What is your name?”
“Where are you?” and
“What time is it?”

Orientation
Time:
“What time is it?”
“What day of the week is today?”
“What month and date is it today?”
“What season is it?”

Guidelines for Assessing Orientation, Alertness, and Memory
Interview Questions to Assess Orientation
Person: “What is your name?” , “What is your wife’s name?” If names can’t be
given, can the person describe roles?
Place: “What is your address?”
“What is the name of this place?”
“What kind of place is this?”
“What is the name of this city?”
“What is the name of this state?”
Note: Examples of direct questions are identified by quotation marks to
distinguish them from the questions that are answered indirectly through
observations.

6. Memory
Recent memory- new, fresh and current info
- ability to recall events in immediate past and up to
two weeks previously.
Remote memory- distant, far-off memory
- ability to recall remote past experiences such as
the date and place of birth, names of schools
attended and chronologic data relating to previous
illness.

6. Memory
Interview Questions to Assess Memory
Remote events:
“Where were you born?”
“Where did you go to grade school?”
“What was your first job?”
“When were you married?”
Recent past events
“Do you live with anyone?”
“Do you have any grandchildren?”
“What are the names of your grandchildren?”
“When was the last time you went to the doctor?”

6. Memory
Immediate memory, retention
 State three unrelated words and ask the person to repeat
the information, both immediately and again after minutes.
 Immediate memory, general grasp and recall: Ask the person
to read a short story and then to summarize the information
presented in the story.
 Immediate memory, recognition: Ask a multiple-choice
question and then ask the person to choose the correct
answer.

The nurse directly assesses memory, both recent and remote, by asking
questions with verifiable answers. For example, if the nurse asks, “Do you
have any memory problems?” the client may inaccurately respond “no,” and
the nurse cannot verify that. Similarly, if the nurse asks, “What did you do
yesterday?” the nurse may be unable to verify the accuracy of the client’s
responses. Hence, questions to assess memory generally include the
following:
• What is the name of the current president?
• Who was the president before that?
• In what county do you live?
• What is the capital of this state?
• What is your social security number?

The nurse assesses the client’s ability to concentrate by 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.” (The nurse should give the
instructions at one time.)

When assessing intellectual functioning, the nurse must consider the client’s
level of formal education. Lack of formal education could hinder performance
in many tasks in this section of the assessment.
 The nurse assesses the client’s ability to use abstract thinking, which is to
make associations or interpretations about a situation or comment. The nurse
can usually do so by asking the client to interpret a common proverb .
 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.

•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.
Literal translation: Don’t forget to sew up holes
in your clothes (concrete thinking).
Proverb: People who live in glass
houses shouldn’t throw stones.
Abstract meaning: Don’t criticize
others for things you also may be
guilty of doing.
Literal translation: If you throw a
stone at a glass house, the glass will
break (concrete thinking).
Note: consider the client’s
level of education

6. Memory
Abstract thinking and intellectual abilities
- Nurse can also asks patient to identify similarities
between pairs of object.
Example:
What is the similar about an apple and an orange?
What the television and the newspaper have in common?
Note: consider the client’s level of education

• Abnormal Sensory Experiences or Misperceptions
hallucinations - false sensory perceptions or
perceptual experiences that do not really exist.
Hallucinations can involve the five senses and bodily
sensations.

6. Memory
Sensory –Perceptual Alterations
Hallucinations- false sensory perceptions or perceptual
experiences that do not really exist
Auditory hallucinations- hearing voices are the most
common
Visual hallucinations-seeing things that do not exist,
second most common

• Judgment (interpretation of environment)
• Decision-making ability
• Insight (understanding one’s own part in current situation)

Judgment refers to the ability to interpret one’s environment and
situation correctly and to adapt one’s 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.

Insight is the ability to understand the true nature of one’s
situation and accept some personal responsibility for that
situation. The nurse can frequently infer insight from the client’s
ability to realistically describe the strengths and weaknesses of his
or her behavior.
An example of poor insight would be a client who places all blame
on others for his own behavior, saying
“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.

• Personal view of self
• Description of physical self
• Personal qualities or attributes

Self-concept is the way one views
oneself in terms of personal worth and
dignity. To assess a client’s self-concept,
the nurse can ask the client to describe
him or herself, what characteristics he
or she likes, and what he or she would
change. The client’s description of self in
terms of physical characteristics gives
the nurse information about the client’s
body image,
which is also part of self-concept.

8. Self-Concept- ways of viewing self in terms of personal
worth and dignity
Example:
Ask the client to describe himself and characteristics he
wants to change
9. Roles and Relationship
Common questions:
Do you feel close to your family?
Do you have a relationship with significant others?

• Current roles
• Satisfaction with roles
• Success at roles
• Significant relationships
• Support systems
Common questions include the following:
• 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
relationships?

10. Physiologic and Self-care considerations
 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 to 3 hours a night
 Bipolar client may not sleep or eat for days
 Major depression may not be able to get out of bed
Assess the ff:
Eating habits, sleeping patterns, health problems,
compliance with prescribed medications, and ADL

• Eating habits
• Sleep patterns
• Health problems
• Compliance with prescribed medications
• Ability to perform the activities of daily living

 involves thinking about the overall assessment rather than
focusing on isolated bits of information.
 The nurse looks for patterns or themes in the data that lead to
conclusions about the client’s strengths and needs and to a
particular nursing diagnosis

 Assessment is an ongoing, dynamic
process, not a one-time activity.
 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

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