Component Task: Assessment of Mental Health Status of a Psychiatric Patient

This is a clinical assessment process that is used to observe and describe a patient’s psychological functioning at a given point in time. It involves the systematic gathering of the patient’s subjective and objective information.

Aims

·         Gather baseline data

·         Obtain useful information in formulating a diagnosis

·         Plan effective nursing and medical care

·         Monitor and evaluate the progress of patient’s response to treatment

Requirements

·         Table

·         Chair

·         Pen and paper

·         Patient’s folder (Electronic/ Manual)

Steps

1.        Welcome patient and offer a comfortable seat

2.      Use simple clear language the patient understands

3.      Establish rapport (refer procedure) and explain the reason for the interaction

4.      Ensure privacy and assure patient of confidentiality

5.      Obtain information from the following areas:

·         Appearance - grooming, facial expression, deformity, etc.

·         General Attitude - cooperative, hostile, overly anxious etc.

·         Motor Activity - hyperactivity, retardation, gait, etc.

·         Thought Process

ü  Thought form - word salad, thought block, flight of ideas etc.

ü  Thought content - delusions, suicidal ideation, magical ideation, etc.

·         Speech - rate, coherent, stuttering, etc.

·         Emotions

ü  Mood – irritable, euphoria, depression, etc.

ü  Affect – congruence, blunt, flat, etc.

·         Perceptual disturbances - hallucinations, illusion, depersonalization, etc.

·         Sensorium and Cognitive ability - orientation, memory, consciousness, etc.

·         Impulse control – aggression, affection, sexual feeling, etc.

·         Judgment and Insight - arithmetic ability, awareness of illness, decision making, etc.

6.      Express appreciation to patient

7.       Document assessment findings in the nurse’s note/ patient folder