CLIENT ASSESSMENT

USING THE NURSING

PROCESS.

OLADOKUN, M.O
 NURSING PROCESS IN PSYCHIATRIC AND MENTAL
HEALTH.

OBJECTIVES
1. Define nursing process.
2. Identify six steps of nursing process.
3. Describe nursing actions related to assessment step include:
 Psychiatric assessment.
 Mental health examination.
4. Identify medical diagnosis(ICD and DSM SYSTEMS)
5. Describe Nursing diagnosis.
 Definition of nursing process
 A systematic rational method of planning and providing individualized
nursing care.
 It is an ongoing dynamic process that continues for as long as nurse and
client have interactions directed toward change in the client's physical or
behavioral responses.

 It is goal directed, with the objective being delivery of quality client care.
Nursing process is dynamic not static.

 Nursing process consists of six steps and uses a problem-solving approach.
SIX(6) STEPS OF NURSING PROCESS.

EVALUATION (RE)ASSESSMENT

IMPLEMENTATION DIAGNOSIS

OUTCOME
PLANNING
IDENTIFICATION
Steps

 Assessing
 Diagnosing
 Planning
 Implementing
 evaluating
 PSYCHIATRIC ASSESSMENT
DEFINITION:
It is a process of collection and organization of data which required for
diagnosis of mental illness.
It may include further assessment as:
1- Laboratory tests.
2- Hospital observation.
3- Psychological testing.
4- Home visits.
 Aims of psychiatric assessment:
1- Discover and diagnose the mental illness.
2- Determine the severity of the diagnosed.
3- Identify the causes of mental illness.
4- Used for setting the management plan.
5- Make a good relationship with clients.
 Methods of psychiatric assessment:

1- Psychiatric History ( patient history).

2- Mental State Examination.

3- Physical Examination.
 Psychiatric history (patient history):
Components of psychiatric history
 Identifying demographic data (Client name, sex, age, marital status,
language, interview time , date, and place... etc).
 Chief complain (Write patient's own words and use Open ended questions).
 History of present illness: With analysis the present complain by (PQRST)
method.
 History of past illness/admission:
• Past psychiatric and medical-surgical history.
• Past personal history:
 Mental Status Examination ‘MSE’
Definition: One of the neurological examinations needed for mental status and
cerebral function testing to reach a tentative diagnosis.
Components of MSE :
1. General Appearance
 Nutritional status
 Hygiene and dress
 Eye contact
 Components of MSE cont’d

2. Psychomotor behaviour
Level of activity
Posture, sitting and walking (Pacing increased in mania).
Facial expression (Sad face in anxiety, and mask face may refer to Parkinson).
Movement (Mannerisms refer to schizophrenia, and hand tremor refer to
anxiety).
3. Mood - Sustained emotion that colors the patient perception of world
around"
Components of MSE cont’d

4. Affect "External expressions of the patient emotion which observed

by examiner"
Appropriate or Inappropriate to situation
5. Speech
Amount
Speed.
Articulation
Rhythm (Heterotonous/monotonous).
 Components of MSE cont’d

6.Thought
Thought Content
7. Perception
Hallucination "False perception without external stimulus".
Illusions "False perception with real external stimulus".
 Components of MSE cont’d

8.Consciousness level .
Orientation
Concentration "Ability to keep one's attention on a certain task".
Memory "Short (5- 10 min), long (24 hr), intermediate (less than 1min),
remote (years ago)" .
Abstract thinking "Ability to explain and deal with concepts as proverbs".
Components of MSE cont’d
9. .Impulse Control
- Ability to control sexual, aggressive and other impulses.
10. Reliability
- Veracity of gathered information.
Medical diagnosis(ICD & DSM systems)
ICD-10
 Organic including symptomatic mental disorders eg Dementia,
Delirium, organic hallucinosis, catatonic disorder.
 Mental and behavioural disorder, due to psychoactive substance use.
 Schizophrenia, schizotypal and delusional disorders.
 Mood (affective) disorders.
 Neurotic, stress related and somatoform disorders.
 Behavioural syndrome.
 Disorders of adult personality and behaviour.
 Behavioural and emotional disorders.
DSM V (diagnostic and statistical manual for mental disorder)

 Neurodevelopmental disorders  Trauma and stressor-related

 Schizophrenia spectrum and disorders
psychotic disorders  Dissociative disorders
 Bipolar and related disorders  Somatic symptoms and related
 Depressive disorders disorders
  Feeding and eating disorders
Anxiety disorders
  Elimination disorders.
Obsessive – compulsive and
related disorders
 DSM-V (diagnostic statistical manual for mental disorders).

 Sleep-wake disorders
 Sexual dysfunctions
 Gender dysphoria
 Disruptive, impulse-control, and conduct disorders
 Substance related and addictive disorders
 Neurocognitive disorders
 Personality disorders
 Paraphilic disorders
 Other Mental Disorders
 Medication-induced movement disorders and other adverse effects of drugs.
 Other Conditions That May Be a Focus of Clinical Attention
 NURSING DIAGNOSIS
It is the second step, data gathered during the assessment are analysed
to determine diagnosis or problems , including level of risks.

Diagnosis and potential problem statement are formulated and

prioritized. Diagnosis conform to accepted classification systems such
as NANDA International Nursing Diagnosis Classification.

A nursing diagnosis provides the basis for selection of nursing

interventions to achieve outcomes for which the nurse is accountable
(NANDA International 2009A).
Nursing diagnosis.
 Examples of Nursing diagnosis for a newly admitted client with the
medical diagnosis or schizophrenia include:
1. Disturbed sensory perception, auditory(evidenced by hearing voices).
2. Disturbed thought processes(evidenced by delusions)
3. Low self esteem (evidenced by fear of failure and social withdrawal)
4. Self care deficit(evidenced by poor personal hygiene)
Note: Nursing diagnosis are prioritized according to life threatening potential.
Maslow’s hierarchy of needs is a good model to follow in prioritizing nursing
diagnosis.
 Nursing Care
 Psychological Approach
 Assessment of patient’s situation – history taking etc.
 Involve family in patient’s care
 Reality treatment
 Be concerned and show empathy
 Provide diversional and recreational activities
 Make use of therapeutic communication skills –
acceptance, listening, clarification, repetition
 Be calm and avoid showing any fear or panic
 Psychotherapy – individual, group therapy, occupational
therapy
Nursing Care contd.
 Social Approach
 Assessment to know the cause of the behaviour
 Have thorough knowledge and understanding of
the patient and his/her complaints
 Give psychological support
 Show him recognition and ensure no harm come to
him or others
 Adjust the environment to relieve patient’s
condition
 Nursing Care contd.
 Physical care
 Nutrition
 Bowel care
 Physical hygiene
 Health education and counselling
 Chemotherapy - e.g. sedatives
 Physical therapy - ECT