Instructional Module in NCM 117a (Care of Clients with Maladaptive Patterns of Behavior, Acute and

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CHAPTER II. THE NURSING PROCESS IN PSYCHIATRIC MENTAL HEALTH CARE

The nursing process is a systematic, rational method of planning and providing

individualized nursing care. This chapter provides you with fundamental knowledge about
the nursing process in the care of clients with mental disorders.

Specifically, the significant concepts that you need to learn in this chapter include
the following:

Lesson 1 - Assessment
Lesson 2 - Nursing Diagnosis
Lesson 3 - Planning and Implementation of Care
Lesson 4 - Health Education
Lesson 5 - Recording and Reporting
Lesson 6 - Evaluation of Care

LESSON 1: ASSESSMENT

INTRODUCTION OF THE LESSON

AND PRESENTATION OF OUTCOMES

Assessment is the initial step of the nursing process. It involves the collection,
organization, and analysis of data about the client’s health. Assessment serves as the basis
for developing a care plan to address the client’s needs. Besides, assessment generates
baseline data used to evaluate the effectiveness of interventions or a measure to determine
the client’s progress (American Nurses Association, 2014, as cited in Videbeck, 2017).

This lesson focuses on how nurses do assessment and what nurses assess in clients
with mental disorders. In particular, this lesson covers Gordon’s functional health patterns,
psychosocial assessment, and cultural and spiritual assessment. Aside from these, other
assessment methods and tools are included in this lesson. These assessment methods and
tools include psychological tests and diagnostic and laboratory examinations.

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LEARNING OUTCOMES FOR THIS LESSON

At the end of this lesson, you must have:

1. recognized the relevance of Gordon’s functional health patterns in

the assessment of clients with mental disorders;
2. described the different components of psychosocial assessment;
3. identified the foci of cultural and spiritual assessment; and
4. recognized the relevance of the different diagnostic and laboratory
examinations in caring for clients with mental disorders.

WARM-UP ACTIVITY. Recall how you assess clients suffering from

medical-surgical conditions. In what way do you think the
assessment of clients with mental disorders varies?

CENTRAL ACTIVITIES

This part of the lesson includes four learning inputs and activities. You need to
accomplish the activities and submit them in the designated folders of this lesson.

LEARNING INPUT 1.

Gordon’s Functional Health Patterns

Marjorie Gordon (Gordon 1994, 2009 as cited in Potter et al., 2013) suggested
functional health patterns to guide the collection of comprehensive assessment data about
clients. These functional health patterns make possible a systematic and standardized
approach to data collection and enable nurses to determine the aspects of health and
human function to plan nursing care for their clients.

An assessment moves from the general to the specific. For instance, all of Gordon’s
11 functional health patterns are assessed and determine if patterns or problems appear in
the data. Then more focused questions are asked about the health patterns that suggest the
existence of a problem. Lastly, patterns of behavior and physiological responses relating to a
functional health category are organized.

The complete assessment of the 11 functional health patterns represents the

patient's interaction and the environment, which Gordon calls biopsychosocial integration.
According to Gordon (1994, as cited in Potter et al., 2013), the nurse cannot understand one
health pattern without knowing the other patterns. Ultimately the nurse’s assessment
identifies functional patterns (patient strengths) and dysfunctional patterns (nursing
diagnoses) that help in nursing care plan development. The 11 functional health patterns

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are presented in the following discussion based on the descriptions of Gordon (1994, 2009
as cited in Potter et al., 2013, & Dowding, n.d.).

Health Perception–Health Management Pattern

This aspect describes the patient’s self-report of health and well-being, how the
patient manages health (e.g., frequency of health care provider visits, adherence to
therapies at home), and knowledge of preventive health practices. Habits that may be
detrimental to health are also evaluated, including smoking and alcohol or drug use. Actual
or potential problems related to safety and health management may be identified and
needs for modifications in the home or needs for continued care in the home.

Nutritional-Metabolic Pattern

This category describes the patient’s daily/weekly pattern of food and fluid intake
(e.g., food preferences or restrictions, special diet, appetite), actual weight, weight loss, or
gain. The adequacy of local nutrient supplies is evaluated. Actual or potential problems
related to fluid balance, tissue integrity, and host defenses may be identified as well as
problems with the gastrointestinal system.

Elimination Pattern

This aspect describes the patient’s patterns of excretory function (bowel, bladder,
and skin). Excretory problems such as incontinence, constipation, diarrhea, and urinary
retention may be identified.

Activity-Exercise Pattern

This category describes the patient’s patterns of exercise, activity, leisure, and
recreation; and ability to perform activities of daily living. The status of major body systems
involved with activity and exercise is evaluated, including the respiratory, cardiovascular,
and musculoskeletal systems.

Sleep-Rest Pattern

This aspect describes the patient’s patterns of sleep, rest, and relaxation.
Dysfunctional sleep patterns, fatigue, and responses to sleep deprivation may be identified.

Cognitive-Perceptual Pattern

This category describes the patient’s sensory-perceptual patterns; language

adequacy, memory, and decision-making ability. Data about neurological functions are
collected to aid this process. Sensory experiences such as pain and altered sensory input
may be identified and further evaluated.

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Self-Perception–Self-concept Pattern

This aspect describes the patient’s self-concept pattern and perceptions of self (e.g.,
self-concept/worth, emotional patterns, body image). The person's level of self-esteem and
response to threats to his or her self-concept may be identified.

Role-Relationship Pattern

This category describes the patient's patterns of role engagements and relationships.
Satisfaction with roles, role strain, or dysfunctional relationships may be further evaluated.

Sexuality-Reproductive Pattern

This aspect describes the patient’s patterns of satisfaction and dissatisfaction with
sexuality, patient’s reproductive patterns, premenopausal and postmenopausal problems.
Concerns with sexuality may be identified.

Coping–Stress Tolerance Pattern

This category describes the patient’s ability to manage stress, sources of support,
and effectiveness of the patterns in terms of stress tolerance. Support systems are
evaluated, and symptoms of stress are noted. The effectiveness of a person's coping
strategies in terms of stress tolerance may be further evaluated.

Value-Belief Pattern

This aspect describes the patient’s patterns of values, beliefs (including spiritual beliefs
and practices), and goals that guide the patient’s choices or decisions.

ACTIVITY 1. Based on your knowledge of the different

manifestations of mental disorders, describe the relevance of
Gordon’s Functional Health Patterns in assessing clients with mental
disorders.

Submit your output for this activity in the submission folder 1 of this lesson.

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LEARNING INPUT 2.

Psychosocial Assessment

Psychosocial assessment includes a mental status examination. The purpose of the

psychosocial assessment is to construct a picture of the client’s current emotional state,
mental capacity, and behavioral function.

The patient must develop a sense of trust before he or she is comfortable revealing
intimate life details. It is also of paramount importance that the nurse has a healthy
knowledge of him- or herself. The nurse’s own biases and values, which may differ from
those of the patient, can influence the nurse’s interpretation of assessment data. A careful
self-assessment helps the nurse interpret the data objectively. Self-awareness is vital in any
interaction. To understand a patient’s self-concept, the nurse must be aware of his or her
self-concept. By answering these questions, nurses can evaluate self-concept components
and increase their self-understanding. The more comfortable the nurse is with him- or
herself, the more effective the nurse can be in every patient interaction (Boyd, 2018).

Factors Influencing Assessment

According to Videbeck (2020), client- and nurse-related factors influence the

assessment of individuals with mental disorders. These factors include client
participation/feedback, client’s health status, client’s previous experiences/misconceptions
about health care, client’s ability to understand, and nurse’s attitude and approach.

Client Participation/Feedback. A thorough and complete psychosocial

assessment requires active client participation. If the client is unable or unwilling to
participate, some assessment areas will be incomplete or vague. For example, the client
who is extremely depressed may not have the energy to answer questions or complete the
assessment. Clients exhibiting psychotic thought processes or impaired cognition may have
a short attention span or may not comprehend the questions being asked. For this reason,
the nurse may need to have several contacts to complete the assessment or gather further
information as the client’s condition permits. This move is necessary for building a picture of
your client through psychosocial assessment.

Client’s Health Status. The client’s health status can also affect the psychosocial
assessment. If the client is anxious, tired, or in pain, the nurse may have difficulty eliciting
the client’s full participation in the assessment. The information that the nurse obtains may
reflect the client’s pain or anxiety rather than an accurate assessment of the client’s
situation. The nurse needs to recognize these situations and deal with them before
continuing the entire assessment. The client may need to rest, receive medications to
alleviate pain or be calmed before the assessment can continue.

Client’s Previous Experiences/Misconceptions about Health Care. The

client’s perception of his or her circumstances can elicit emotions that interfere with
obtaining an accurate psychosocial assessment. If the client is reluctant to seek treatment or
has had previous unsatisfactory experiences with the health care system, he or she may

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have difficulty answering questions directly. The client may minimize or maximize symptoms
or problems or may refuse to provide information in some areas. The nurse must address
the client’s feelings and perceptions to establish a trusting working relationship before
proceeding with the assessment.

Client’s Ability to Understand. The nurse must also determine the client’s ability to
hear, read, and understand the language being used in the assessment. If the client’s
primary language differs from that of the nurse, the client may misunderstand or
misinterpret what the nurse is asking, which results in inaccurate information. A client with
impaired hearing may also fail to understand what the nurse is asking. The information in
the assessment must reflect the client’s health status; it should not be a result of poor
communication.

Nurse’s Attitude and Approach. The nurse’s attitude and approach can influence the
psychosocial assessment. Suppose the client perceives the nurse’s questions to be short and
curt or feels rushed or pressured to complete the assessment. In that case, he or she may
provide only superficial information or omit discussing problems in some areas altogether.
The client may also refrain from providing sensitive information if he or she perceives the
nurse as non-accepting, defensive, or judgmental. For example, a client may be reluctant to
relate child abuse or domestic violence instances if the nurse seems uncomfortable or non-
accepting. The nurse must be aware of his or her feelings and responses and approach the
assessment matter-of-factly.

How to Conduct the Interview

In interviewing, nurses need to consider several factors. These factors include the
environment, input from family and friends, phrasing questions (Videbeck, 2020), and
nurses' behaviors (Boyd, 2018).

Environment. The nurse should conduct the psychosocial assessment in

a comfortable, private, and safe environment for both the client and the nurse. An
environment that is pretty quiet with few distractions allows the client to give his or her full
attention to the interview. Interviewing in a place such as a conference room assures the
client that no one will overhear what is being discussed. However, the nurse should not
choose an isolated location for the interview, particularly if the client is unknown to the
nurse or has a history of threatening behavior. The nurse must ensure his or her and the
client's safety, even if that means another person is present during the assessment.

Input from Family and Friends. If family members, friends, or caregivers have
accompanied the client, the nurse should obtain their perceptions of the client’s behavior
and emotional state. How this is accomplished depends on the situation. Sometimes, the
client does not permit the nurse to conduct separate interviews with family members. 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. Alternatively, the
client may not feel comfortable participating in the assessment without family or friends.
This, too, may limit the amount or type of information the nurse obtains. It is desirable to
conduct at least part of the assessment without others, especially in suspected abuse or

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intimidation cases. The nurse should make every effort to assess the clients in cases of
suspected abuse privately.

How to Phrase Questions. The nurse may use open-ended questions to start the
assessment. Doing so allows the client to begin as he or she feels comfortable and also gives
the nurse an idea about the client’s perception of his or her situation.

Examples of open-ended questions are as follows:

❖ What brings you here today?

❖ Please tell me what has been happening to you.
❖ How can we help you?

If the client cannot organize his or her thoughts or has difficulty answering open-
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. Questions regarding several
different behaviors or symptoms—“How are your eating and sleeping habits? and Have you
been taking any over-the-counter medications that affect your eating and sleeping?”—can
be confusing to the client. The following are examples of focused or 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?
❖ How many meals a day do you eat?
❖ 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 drug or alcohol use, sexual behavior, abuse or violence,
and child-rearing practices. Using nonjudgmental language and a matter-of-fact tone avoids
giving the client verbal cues to become defensive or not to tell the truth. For example, 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
gives the impression that physical discipline is wrong, and it may cause the client to respond
dishonestly.

Clarification is essential during the assessment process. Words do not have the same
meaning to all people. Education, language, culture, history, and experience may influence
the meaning of words. Sometimes simple and direct questioning provides clarification. In
other situations, the nurse may clarify by providing a specific example for a more global
thought the patient is trying to express. For example, a patient may say, “Things have been
so strange since the children left.” The nurse may respond with, “Sometimes, parents feel
sad and empty when their children leave home. They do not know what to do with their
time.” Frequently summarizing what has been said allows the patient the opportunity to

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correct the nurse’s interpretation. For example, verbalizing a sequence of events that the
patient has reported may help identify omissions or inconsistencies. Restating information
or reflecting feelings that the patient has described also allows an opportunity for
clarification. Nurses must understand exactly what patients are attempting to communicate
before beginning to intervene (Boyd, 2018).

Nurses’ Behaviors. According to Boyd (2018), the following behaviors demonstrated

by the nurse will enhance the effectiveness of the assessment interview:

Exhibiting empathy—to show empathy to the patient, the nurse uses phrases such as, “That
must have been upsetting for you” or “I can understand your hurt feelings.”

Giving recognition—the nurse gives recognition by listening actively: verbally encouraging

the patient to continue, and non-verbally presenting an open, interested demeanor.

Demonstrating acceptance—note that acceptance does not mean agreement or non-

agreement with the patient but is a neutral stance that allows the patient to continue.

Restating—the nurse tries to clarify what the patient is trying to say by restating it.

Reflecting—the nurse presents the patient’s last statement as a question. This gives the
patient a chance to expand on the information.

Focusing—the nurse attempts to bring the conversation back to the questions at hand when
the patient goes off on a tangent.

Using open-ended questions—general questions give the patient a chance to speak freely.

Presenting reality—the nurse presents reality when the patient makes unrealistic or
exaggerated statements.

Making observations—the nurse says aloud what patient behaviors are observed to give the
patient a chance to speak to those behaviors. For example, the nurse may say, “I notice you
are twisting your fingers; are you nervous about something?”

It is crucial to remember that when beginning an assessment of a client, the nurse

must address the client’s feelings and perceptions to establish a trusting working
relationship before proceeding with the assessment. The priority is to create an
environment in which the client feels safe and can trust caregivers. Asking questions that
allow the client to open up to the caregiver helps to establish that relationship.

Moreover, Videbeck (2020) states that the information gathered in a psychosocial

assessment can be organized in many different ways. Most assessment tools or conceptual
frameworks contain similar categories with some variety in arrangement or order. The nurse
should use some organizing framework to assess the client thoroughly and systematically
that lends itself to analysis and serves as a basis for the client’s care. The framework for

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psychosocial assessment contains the following components (and factors under each
component):

History: age, developmental stage, cultural considerations, spiritual beliefs, and

previous history

General Appearance and Motor Behavior: hygiene and grooming, appropriate dress,
posture, eye contact, unusual movements or mannerisms, and speech

Mood and Affect: expressed emotions, and facial expressions

Thought Process and Content: content (what the client is thinking), process (how
the client is thinking), clarity of ideas, and self-harm or suicide urges

Sensorium and Intellectual Processes: orientation, confusion, memory,

concentration and abstract thinking abilities

Abnormal Sensory Experiences or Misperceptions: hallucinations

Judgment and Insight: judgment (interpretation of environment), decision-making

ability, and insight (understanding one’s own part in the current situation)

Self-Concept: personal view of self, description of the physical self, and personal
qualities or attributes

Roles and Relationships: current roles, satisfaction with roles, success at roles,
significant relationships, and support systems

Physiologic and Self-Care Considerations: eating habits, sleep patterns, health

problems, compliance with prescribed medications, and ability to perform the
activities of daily living

Based on Videbeck’s (2020) work, the ensuing discussion presents in detail the
different information that the nurse must gather during a psychosocial assessment. The
presentation starts with the history down to physiologic and self-care considerations.

Components of Psychosocial Assessment

History. Background assessments include the client’s history, age and developmental
stage, cultural and spiritual beliefs, and beliefs about health and illness. The history of the
client and 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? Positive family history for
alcoholism, bipolar disorder, or suicide is significant because it increases the client’s risk for

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these problems. The client’s chronologic age and developmental stage are essential factors
in the psychosocial assessment. The nurse evaluates the client’s age and developmental
level for congruence with expected norms. For example, 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 struggles are normal and anticipated because these are two of
the primary developmental tasks for the adolescent. If the client is 35 years old and still
struggles with self-identity and independence, the nurse will need to explore the situation.
The client’s age and developmental level may also be incongruent with expected norms if
the client has a developmental delay or intellectual disability.

The nurse must be sensitive to the client’s cultural and spiritual beliefs to avoid
making inaccurate assumptions about his or her psychosocial functioning (Schultz &
Videbeck, 2013, as cited in Videbeck, 2020). Many cultures have beliefs and values about
a person’s role in society or acceptable social or personal behavior that may differ from
those of the nurse. Western cultures generally expect that as a person reaches adulthood,
he or she becomes financially independent, leaves home, and makes his or her own life
decisions. In contrast, in some Eastern cultures, three generations may live in one
household, and elders of the family make major life decisions for all. Another example is
the assessment of eye contact. Western cultures consider good eye contact to be a positive
characteristic indicating self-esteem and paying attention. People from other cultures, such
as Japan, consider such eye contact to be a sign of disrespect.

The nurse must not stereotype clients. Just because a person’s physical
characteristics are consistent with a particular race, he or she may not have the attitudes,
beliefs, and behaviors traditionally attributed to that group. For example, many people of
Asian ancestry have beliefs and values that are more consistent with Western beliefs and
values than with those typically associated with Asian countries. To avoid making inaccurate
assumptions, the nurse must ask clients about the beliefs or health practices that are
important to them or how they view themselves in the context of society or relationships.
The nurse must also consider the client’s beliefs about health and illness when assessing the
client’s psychosocial functioning. Some people view emotional or mental problems as family
concerns to be handled only among family members. They may view seeking outside or
professional help as a sign of individual weakness. Others may believe that their problems
can be solved only with the proper medication, and they will not accept other forms of
therapy. Another common problem is the misconception that one should take medication
only when feeling sick. Like some medical conditions, many mental disorders may require
clients to take medications on a long-term basis, perhaps even for a lifetime. Just like people
with diabetes must take insulin, and people with hypertension need antihypertensive
medications, people with recurrent depression may need to take antidepressants on a long-
term basis.

General Appearance and Motor Behavior. The nurse assesses the client’s overall
appearance, including dress, hygiene, and grooming. Is the client appropriately dressed for
his or her age and the weather? Is the client unkempt or disheveled? Does the client appear
to be his or her stated age? The nurse also observes the client’s posture, eye contact, facial
expression, and unusual tics or tremors. He or she documents observations and examples of

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behaviors to avoid personal judgment or misinterpretation. 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

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.

Mood and Affect. Mood refers to the client’s pervasive and enduring emotional
state. Mood refers to the prominent, sustained, overall emotions that the person expresses
and exhibits. Mood may be sustained for days or weeks, or it may fluctuate during a day. For
example, some patients with depression have a diurnal variation in their mood. They
experience their lowest mood in the morning, but as the day progresses, their depressed
mood lifts, and they feel somewhat better in the evening. Terms used to describe mood
include euthymic (normal), euphoric (elated), labile (changeable), and dysphoric (depressed,
disquieted, and restless) (Boyd, 2018). Likewise, the client’s mood may be described as
happy, sad, depressed, anxious, or angry. When the client exhibits unpredictable and rapid
mood swings from depression and crying to euphoria with no apparent stimuli, the mood is
called labile (rapidly changing).

Affect is the outward expression of the client’s emotional state. The client may make
statements about feelings, such as “I am depressed” or “I am elated,” or the nurse may infer
the client’s mood from data such as posture, gestures, tone of voice, and facial expression.
The nurse also assesses for consistency among the client’s mood, affect, and situation. For
instance, the client may have an angry facial expression but deny feeling angry or upset in
any way. Alternatively, the client may be talking about the recent loss of a family member
while laughing and smiling. The nurse must note such inconsistencies. 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

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According to Boyd (2018), affect can be described in terms of range, intensity,

appropriateness, and stability. The range can be full or restricted. An individual who
expresses several different emotions consistent with the stated feelings and content being
expressed is described as having a full range of affect congruent with the situation. An
individual who expresses few emotions has a restricted affect. For example, a patient could
be describing the recent tragic death of a loved one in a monotone with little expression. In
determining whether this response is normal, the nurse compares the patient’s emotional
response with the cultural norm for that particular response.
Intensity can be increased, flat, or blunted. The nurse may find it helpful to ask the client to
estimate the intensity of his or her mood. The nurse can do so by asking the client to rate his
or her mood on a scale of 1 to 10. For example, if the client reports being depressed, the
nurse might ask, “On a scale of 1 to 10, with 1 being least depressed and 10 being most
depressed, where would you place yourself right now?”

The nurse determines whether the emotional response is appropriate for the
situation. For example, an inappropriate response is shown by a patient who has an extreme
reaction to the death of the victims of a tragedy as if the victims were personal friends.
Another patient said that his life stopped when the World Trade Center towers came down.
He could not eat or sleep for weeks afterward.

Stability can be mobile (normal) or labile. If a patient reports feeling happy one
minute and reduced to tears the next, the person probably has an unstable mood. During
the interview, the nurse should look for rapid mood changes that indicate lability of mood. A
patient who exhibits intense, frequently shifting emotional extremes has a labile affect.

Thought Process and Content. 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. The nurse assesses whether the client’s
verbalizations make sense, if ideas are related and flow logically from one to the next. The
nurse must also 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, he or she may find it helpful to ask focused
questions requiring short answers. Common terms related to the assessment of thought
process and content include the following:

Circumstantial thinking: a client eventually answers a question but only after giving
excessive, unnecessary detail

Delusion: a fixed false belief not based on reality

Flight of ideas: excessive amount and rate of speech composed of fragmented or unrelated
ideas

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

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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
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

Word salad: the flow of unconnected words that convey no meaning to the listener

Assessment of suicide or harm toward others is also an important aspect of

assessment. The nurse must determine whether the depressed or hopeless client
has suicidal ideation or a 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?” The assessment
questions the nurse should ask any client who has suicidal ideas include:

Ideation: “Are you thinking about killing yourself?”

Plan: “Do you have a plan to kill yourself?”
Method: “How do you plan to kill yourself?”
Access: “How would you carry out this plan? Do you have access to the means to carry out
the plan?”
Where: “Where would you kill yourself?”
When: “When do you plan to kill yourself?”
Timing: “What day or time of day do you plan to kill yourself?”

Likewise, if the client is angry, hostile, or making threatening remarks about a family
member, spouse, or anyone else, the nurse must ask whether 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 (person’s name)?

❖ What is your plan?
❖ What do you want to do to (person’s name)?

When a client makes specific threats or has a plan to harm another person, health
care providers are legally obligated to warn the person who is the target of the threats or
plan. The legal term for this is the duty to warn. This is one situation in which the nurse
must breach the client’s confidentiality to protect the threatened person.

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Sensorium and Intellectual Processes. The assessment of this aspect involves

collecting data on the client’s orientation, memory, ability to concentrate, and abstract
thinking and intellectual abilities.
Orientation refers to the client’s 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 often
documented as “oriented × 3.” Occasionally, a fourth sphere, situation, is added (whether
the client accurately perceives his or her current circumstances). The absence of correct
information about person, place, and time is referred to as disorientation, or “oriented × 1”
(person only) or “oriented × 2” (person and place). The order of person, place, and time is
significant. When a person is disoriented, he or she first loses track of time, then place, and,
finally, person. Orientation returns in the reverse order; first, the person knows who he or
she is, then realizes place, and, finally, time. Disorientation is not synonymous with
confusion. A confused person cannot make sense of his or her surroundings or figure things
out even though he or she may be fully oriented.

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 country?
❖ What is your social security number?

Moreover, to check immediate and short-term memory, the nurse gives the patient
three unrelated words to remember and asks him or her to recite them right after telling
them and at 5- and 15-minute intervals during the interview. To test recent memory, the
nurse may question about a holiday or world event within the past few months. The nurse
tests long-term or remote memory by asking about events years ago. If they are personal
events and the answers seem incorrect, the nurse may check them with a family member
(Boyd, 2018).

The nurse assesses the client’s ability to concentrate by asking the client to perform
specific 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.)

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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 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 such as “a stitch in time saves nine.” 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. For instance:

Proverb: A stitch in time saves nine.

Abstract meaning: If you take the time to fix something now, you will avoid bigger problems
in the future.
Literal translation: Do not forget to sew up holes in your clothes (concrete thinking).
Proverb: People who live in glass houses should not throw stones.
Abstract meaning: Do not criticize others for things you also may be guilty of doing.
Literal translation: If you throw a stone at a glasshouse, the glass will break (concrete
thinking).

The nurse may also assess the client’s intellectual functioning by asking him or her to
identify the similarities between pairs of objects. For example, “What is similar about an
apple and an orange?” or “What do the newspaper and the television have in common?”

Sensory–Perceptual Alterations. Some clients experience hallucinations (false

sensory perceptions or perceptual experiences that do not exist). Hallucinations can involve
the five senses and bodily sensations. Auditory hallucinations (hearing voices) are the most
common; visual hallucinations (seeing things that do not exist) are the second most
common. Initially, clients perceive hallucinations as actual experiences, but later in the
illness, they may recognize them as hallucinations.

Judgment and Insight. 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. For example, the client may spend large
sums of money on frivolous items when he or she cannot afford necessities such as food or
clothing. Risky behaviors such as picking up strangers in bars or engaging in unprotected
sexual activity may also indicate poor judgment. The nurse may also assess a client’s
judgment by asking the client hypothetical questions, such as “If you found a stamped
addressed envelope on the ground, what would you do?”

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 behavior, saying, “It is my wife’s fault that I drink and get into fights because she nags

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me all the time.” This client is not accepting responsibility for his or her drinking and
fighting. Another example of poor insight would be the client who expects all problems to
be solved with little or no personal effort: “The problem is my medication. As soon as the
doctor gets the medication right, I will be just fine.”

Self-Concept. 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.

Also included in assessing self-concept are the emotions that the client frequently
experiences, such as sadness or anger, and whether the client is comfortable with those
emotions. The nurse must also assess the client’s coping strategies. He or she can do so by
asking, “What do you do when you have a problem? How do you solve it? What usually
works to deal with anger or disappointment?”

Roles and Relationships. People function in their communities 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. The number and type of roles may vary,
but they usually include family, occupation, and hobbies or activities. Family roles include
son or daughter, sibling, parent, child, and spouse or partner. Occupation roles can be
related to a career or school, or both. The ability to fulfill a role or the lack of the desired
role is often central to the client’s psychosocial functioning. Changes in roles may also be
part of the client’s difficulty.

Relationships with other people are essential to one’s 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 client’s life, the client’s satisfaction with those relationships, or any loss of relationships.
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?

If the client’s family relationships seem to be a significant source of stress or if the

client is closely involved with his or her family, a more in-depth assessment of this area may
be helpful. The areas of family functioning and practices that are commonly
assessed include:

❖ Parenting practices, such as methods of discipline, supervision of children, rules

❖ Patterns of social interaction among family members, expression of feelings

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❖ Patterns of problem-solving and decision-making

❖ Problems related to housing, finances, transportation, child care
❖ Relationships with extended family members
❖ Health behaviors such as mental or physical illness, disabilities, alcohol and drug use

Many people spend many hours daily on various social media sites. Contacts are
referred to as friends even though they may know almost nothing about them or provide
inaccurate information. It is helpful to distinguish between face-to-face contact with others
versus online contact. A balance of online social activity with real-time presence and
interaction is usually preferable for one’s mental health. Online activities such as Facebook
and Skype can sometimes enhance real-life relationships.

Physiologic and Self-Care Considerations. When doing a 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 significantly 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 be unable to
sleep more than 2 or 3 hours a night. Clients with bipolar disorder may not eat or sleep for
days. Clients with major depression may not be able to get out of bed. Therefore, the nurse
must assess the client’s usual eating and sleeping patterns and then determine how those
patterns have changed.

The nurse also asks the client whether he or she has any major or chronic health
problems and whether he or she takes prescribed medications as ordered and follows
dietary recommendations. The nurse also explores the client’s use of alcohol and over-the-
counter or illicit drugs. Such questions require nonjudgmental phrasing; the nurse must
reassure the client that truthful information is crucial in determining the client’s care plan.

Noncompliance with prescribed medications is an important area. If the client has

stopped taking medication or is taking medication other than as prescribed, the nurse must
help the client feel comfortable enough to reveal this information. The nurse also explores
the barriers to compliance. Is the client choosing noncompliance because of undesirable
side effects? Has the medication failed to produce the desired results? Does the client have
difficulty obtaining the medication? Is the medication too expensive for the client?

ACTIVITY 2. Considering your learning at this point, describe the

different components of psychosocial assessment briefly.

Submit your output for this activity in the submission folder 2 of this lesson.

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LEARNING INPUT 3.

Cultural and Spiritual Assessment

Boyd (2018) affirms that culture can profoundly affect a person’s worldview. Culture
helps a person frame beliefs about life, death, health and illness, and roles and
relationships. During a cultural assessment, the nurse must consider factors that influence
the manifestations of the current mental disorder. For example, a patient mentions
“speaking in tongues.” The nurse may identify this experience as a hallucination when, in
fact, the patient was having a religious experience common within some branches of
Christianity. In this instance, knowing and understanding such religious practices will
prevent a misinterpretation of the symptoms. The nurse can elicit important cultural
information by asking the following questions:

❖ To what cultural group do you belong?

❖ Were you raised in an ethnic community?
❖ How do you define health?
❖ How do you define illness?
❖ How do you define good and evil?
❖ What do you do to get better when you are physically ill? Mentally ill?
❖ Whom do you see for help when you are physically ill? Mentally ill?
❖ By what cultural rules or taboos do you try to live?
❖ Do you eat special foods?

Furthermore, spirituality, the search for meaning and purpose in the human
experience, is an essential part of the recovery process and is recognized as a critical
component of wellness. Several studies show that spirituality and religion play an important
role in coping with mental disorders through providing hope, comfort, meaning of life, and
serve as a resource for coping with symptoms, substance abuse, and protection against
suicide (Mohr et al., 2012; Gomi et al., 2014, as cited in Boyd, 2018). Many patients wish to
examine their spiritual and religious beliefs with the health care clinicians who may or may
not be comfortable with these discussions. In recovery-oriented treatment facilities, there
may be groups designed explicitly for spirituality.

Nurses must be clear about their spirituality to be sure it does not interfere with the
assessment of the patient’s spirituality. At a minimum, a screening assessment should be
done addressing the following topics with a referral to a trained individual (Mohr &
Huguelet, 2014, as cited in Boyd, 2018):

❖ How important is spirituality and/or religion in life and coping with an illness?
❖ Are you involved in a religious community?
❖ Would you like to address these issues in your mental health care?
❖ If yes, with whom would you like to address these issues?

Spiritual assessment questions need to correspond to the patient’s readiness to

discuss this topic. Patients and clinicians agree that it may take time for the patient to feel
comfortable and ready to discuss spirituality. Questions must be asked that focus on a

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patient’s strengths. For example, asking the question, “Was there a time in your life where
you felt great peace and joy and maybe not so stressed out?” is less judgmental than the
question, “What were your sources of deep meaning, peace, joy, and strength . . . ?” The
latter statement implies that there should be sources (religious, spiritual) that exist.
Examples of questions that could help patients examine past or current spiritually related
strengths and resources include the following (Gomi et al., 2014, as cited in Boyd, 2018):

❖ Was there a time in your life when you felt at peace?

❖ What do you do to get through the tough times (pray, meditate, visit nature,
family)?
❖ When do you feel most positive about yourself?
❖ What brings inspiration to your life?

Questions that can help the individual connect to spiritual goals to recovery goals (if that is a
goal of the person) include the following (Gomi et al., 2014, as cited in Boyd, 2018):

❖ What helps you feel good or hopeful about your life?

❖ Is spirituality something you want to connect with your recovery?
❖ Based on what you said, how would you say your spirituality could support your
recovery?

ACTIVITY 3. Based on your understanding, describe the relevance of

cultural and spiritual assessment in caring for individuals with
mental disorders.

Submit your output for this activity in the submission folder 3 of this lesson.

LEARNING INPUT 4.

Other Assessment Methods and Tools

In assessing clients with mental disorders, other assessment methods and tools are
used, particularly by other members of the health care team. These include psychological
tests and diagnostic and laboratory examinations. Nurses also use the findings generated
from these assessments in developing appropriate care for clients with mental disorders.

Psychological Tests

Psychological tests are another source of data for the nurse to use in planning care
for the client. Two basic types of tests are intelligence tests and personality tests (Videbeck,
2020).

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Intelligence tests are designed to evaluate the client’s cognitive abilities and
intellectual functioning. Intelligence tests are used in assessing individuals with intellectual
disability (ID), also referred to as intellectual developmental disorder (a
neurodevelopmental disorder) characterized by deficits in intellectual and adaptive
functioning. The four standardized and clinically and legally accepted measures of
intellectual function include Wechsler Intelligence Scales, Stanford-Binet Intelligence Scales,
the Bayley Scales of Infant and Toddler Development, and the Kauffman Assessment Battery
for Children, Second Edition (Bisconer & Ahsan, 2017).

The Wechsler scales include three individually administered scales of intelligence.

The Wechsler Preschool and Primary Scale of Intelligence – Fourth Edition (WIPPSI-IV)
measures cognitive development in preschoolers and young children ages 2.6–7.7 years
(Wechsler, 2012, as cited in Bisconer & Ahsan, 2017). The Wechsler Intelligence Scale for
Children – Fifth Edition (WISC–V) measures a child’s intellectual ability and is appropriate for
children 6.0–16.11 years (Wechsler, 2014, as cited in Bisconer & Ahsan, 2017). The Wechsler
Adult Intelligence Scale – Fourth Edition (WAIS-IV) measures an adult’s intellectual ability
and is appropriate for persons 16.0–90.11 years (Wechsler, 2008, as cited in Bisconer &
Ahsan, 2017).

The Stanford-Binet Intelligence Scales, Fifth Edition (SB5) is an individually

administered measure of intelligence and cognitive abilities for persons 2–85 years and
older. The SB5 is used to diagnose a wide variety of developmental disabilities. It can be
used as part of early childhood assessment, psychoeducational evaluations for special
education services, and later career development planning (Royd, 2003, as cited in Bisconer
& Ahsan, 2017).

The Bayley Scales of Infant and Toddler Development, Third Edition (Bayley III)
(Bayley, 2005, as cited in Bisconer & Ahsan, 2017) are used to assess the developmental
status of children ages one month to 42 months. This assessment takes 30–90 min to
administer, depending on the age of the child. The scales measure the complete child in five
areas:
1. Cognitive (visual preference, attention, memory, sensorimotor, exploration, and
manipulation, concept formation);
2. Motor (fine motor and gross motor subtests);
3. Language (receptive and expressive subtests);
4. Social-emotional (communicating needs, self-regulation using emotional signals);
and
5. Adaptive behavior (communication, self-care, self-direction).

Care-giver participation is encouraged, and a care-giver report with recommendations is

generated. The Bayley III Screening Test (Bayley, 2005b, as cited in Bisconer & Ahsan, 2017)
is used for ongoing screening, monitoring, and reassessment in children. The assessment is
easily administered in 15–20 minutes and provides cognitive, language, and motor domain
scores and cut scores according to age. The assessment is helpful in pediatric offices,
daycare centers, and early intervention programs.

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The Kaufman Assessment Battery for Children, Second Edition (KABC-II) (Kaufman
and Kaufman, 2004a, as cited in Bisconer & Ahsan, 2017) is appropriate for children ages 3–
18 years. The scales and subscales are designed to minimize verbal instructions and
responses. Test items contain limited cultural content, which limits cultural bias. KABC-II
scales include simultaneous processing, sequential processing, planning, learning, and
knowledge. The KABC-II is considered a better predictor of intellectual ability in children
with intellectual limitations than other assessments of intelligence because it measures
intellectual ability without emphasizing academic and verbal skills. The Kaufman Brief
Intelligence Test (KBIT-2) (Kaufman and Kaufman, 2004b, as cited in Bisconer & Ahsan,
2017) is a screening tool that includes two scales: crystalized or verbal scale and fluid or
nonverbal scale. The KBIT-2 can be used (a) to re-evaluate the intellectual status of a child or
adult who has previously received comprehensive assessment; (b) as a screening tool to
identify high-risk children who will need a referral for comprehensive assessment; and (c) as
an assessment of intellectual ability in children and adults residing in institutional settings.

On the other hand, personality tests reflect the client’s personality in self-concept,
impulse control, reality testing, and major defenses. Personality tests may be objective
(constructed of true-or-false or multiple choice questions). Table 1 describes selected
objective personality tests (Adams et al., 2017, as cited in Videbeck, 2020). The client’s
answers are compared with standard answers or criteria and a score or scores are obtained.

Table 1. Objective Measures of Personality

Test Description
Minnesota Multiphasic 567 true–false items; provides scores on 20 primary scales
Personality Inventory-2
(MMPI-2)
Milton Clinical Multiaxial 175 true–false items; provides scores on various
Inventory (MCMI) and MCMI-II personality traits and personality disorders
(revised version)
Psychological Screening 103 true–false items; used to screen for the need for
Inventory (PSI) psychological help
Beck Depression Inventory 21 items rated on scale of 0–3 to indicate the level of
(BDI) depression
Tennessee Self-Concept Scale 100 true–false items; provides information on 14 scales
(TSCS) related to self-concept

Other personality tests, called projective tests, are unstructured and are usually
conducted by the interview method. The stimuli for these tests, such as pictures or
Rorschach’s inkblots, are standard, but clients may respond with answers that vary widely.
The evaluator analyzes the client’s responses and gives a narrative result of the testing.
Table 2 lists commonly used projective personality tests (Adams et al., 2017, as cited in
Videbeck, 2020).

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Table 2. Projective Measures of Personality

Test Description
Rorschach test 10 stimulus cards of ink blots; client describes perceptions of ink blots;
narrative interpretation discusses areas such as coping styles,
interpersonal attitudes, characteristics of ideation
Thematic 20 stimulus cards with pictures; client tells a story about the picture;
apperception narrative interpretation discusses themes about mood state, conflict,
test (TAT) quality of interpersonal relationships
Sentence Client completes a sentence from beginnings such as “I often wish,”
completion test “Most people,” and “When I was young.”

Both intelligence tests and personality tests are frequently criticized as being
culturally biased. It is essential to consider the client’s culture and environment when
evaluating the importance of scores or projections from any of these tests; they can provide
useful information about the client in some circumstances but may not be suitable for all
clients.

Diagnostic and Laboratory Examinations

According to Townsend (2011), several diagnostic procedures are used to detect

alterations in biological function that may contribute to psychiatric disorders. Following is an
explanation of various examinations, the technique used, the purpose of the examination,
and possible findings.

Electroencephalography. For an electroencephalogram (EEG), electrodes are placed

on the scalp in a standardized position. Amplitude and frequency of beta, alpha, theta, and
delta brain waves are graphically recorded on paper by ink markers for multiple brain
surface areas.

The EEG measures brain electrical activity and identifies dysrhythmias, asymmetries,
or suppression of brain rhythms. It is used in the diagnosis of epilepsy, neoplasm, stroke,
and metabolic or degenerative disease.

Computerized EEG Mapping. EEG tracings are summarized by computer-assisted

systems in which various regions of the brain are identified, and functioning is interpreted
by color-coding or gray shading.

Computerized EEG mapping measures brain electrical activity. It is mainly used in

research to represent statistical relationships between individuals and groups or between
two populations of subjects (e.g., clients with schizophrenia versus control subjects).

Computed Tomographic Scan. A CT scan may be used with or without a contrast

medium. X-rays are taken of various transverse planes of the brain, while a computerized
analysis produces a precise reconstructed image of each segment.

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The CT scan measures the accuracy of brain structure to detect possible lesions,
abscesses, areas of infarction, or aneurysms. This technology has also been used to identify
various anatomical differences in clients with schizophrenia, organic mental disorders, and
bipolar disorder.

Magnetic Resonance Imaging. In magnetic resonance imaging (MRI), within a strong

magnetic field, the nuclei of hydrogen atoms absorb and reemit electromagnetic energy
that is computerized and transformed into image information. No radiation or contrast
medium is used.

MRI measures the anatomical and biochemical status of various segments of the
brain. It also detects brain edema, ischemia, infection, neoplasm, trauma, and other
changes such as demyelination. Morphological differences between the brains of clients
with schizophrenia and those of control subjects have been noted.

Positron Emission Tomography. With positron emission tomography (PET), the

client receives an intravenous injection of a radioactive substance (the type depends on the
brain activity to be visualized). Detectors surround the head and relay data to a computer,
which interprets the signals and produces the image.

PET measures specific brain functioning, such as glucose metabolism, oxygen

utilization, blood flow, and, of particular interest in psychiatry, neurotransmitter/ receptor
interaction.

Single Photon Emission Computed Tomography. The single-photon emission

computed tomography (SPECT) technique is similar to PET. However, a longer-acting
radioactive substance must be used to allow time for a gamma camera to rotate about the
head and gather the data, which then are assembled by computer into a brain image.

SPECT measures various aspects of brain functioning, as with PET; it also has been
used to take images of activity or CSF circulation.

Moreover, the nurse reviews and documents any available laboratory data,
especially any abnormalities. Hepatic, renal, or urinary abnormalities are significant to
document because these systems metabolize or excrete many psychiatric medications. In
addition, the nurse notes abnormal white blood cell and electrolyte levels. Laboratory data
are essential, particularly if the nurse is the only person in the mental health team with a
“medical” background. Table 3 presents selected hematologic measures and their relevance
to psychiatric disorders (Boyd, 2018).

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Table 3. Selected Hematologic Measures and their Relevance to Psychiatric Disorders

Test Possible Results Possible Cause or Meaning
Complete Blood Count (CBC)
Leukocyte (white Leukopenia—decrease in May be produced by: phenothiazine,
blood cell leukocytes (white blood clozapine, carbamazepine
[WBC]) count cells)
Agranulocytosis— Lithium causes a benign mild to moderate
decrease in number of increase (11,000–17,000/mcL)
granulocytic leukocytes
Neuroleptic malignant syndrome (NMS)
Leukocytosis— increase in can be associated with increases of
leukocyte count above 15,000– 30,000/mm3 in about 40% of
normal limits cases
WBC differential “Shift to the left”— from Shift often suggests a bacterial infection
segmented neutrophils to but has been reported in about 40% of
band forms cases of NMS
Red blood cell Polycythemia— increased Primary form—true polycythemia caused
(RBC) count RBCs by several disease states

Secondary form—compensation for

decreased oxygenation, such as in chronic
pulmonary disease

Blood is more viscous, and the patient

should not become dehydrated

Decreased RBCs Decrease may be related to some types of

anemia, which requires further evaluation
Hematocrit (Hct) Elevations Elevation may be caused by dehydration

Decreased Hct Anemia may be associated with a wide

range of mental status changes, including
asthenia, depression, and psychosis
Hemoglobin (Hb) Decreased Another indicator of anemia; further
evaluation of source requires review of
erythrocyte indices
Erythrocyte Elevated RDW Finding suggests a combined anemia as in
indices, such as that from chronic alcoholism, resulting
red from both vitamin B12 and folate acid
cell distribution deficiencies and iron deficiency
width (RDW) Oral contraceptives also decrease vitamin
B12

Other Hematologic Measures

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Vitamin B12 Deficiency Neuropsychiatric symptoms, such as

psychosis, paranoia, fatigue, agitation,
marked personality change, dementia,
and delirium may develop
Folate Deficiency The use of alcohol, phenytoin, oral
contraceptives, and estrogens may be
responsible
Platelet count Thrombocytopenia— Some psychiatric medications, such as
decreased platelet carbamazepine, phenothiazine, or
count clozapine, or other nonpsychiatric
medications, may cause
thrombocytopenia

Several medical conditions are other

causes
Serum Electrolytes
Sodium Hyponatremia—low Significant mental status changes may
serum sodium ensue. Condition is associated with
Addison disease, the syndrome of
inappropriate secretion of antidiuretic
hormone (SIADH), and polydipsia
(water intoxication) and
carbamazepine use
Potassium Hypokalemia—low Produces weakness, fatigue,
serum potassium electrocardiogram (ECG) changes;
paralytic ileus and muscle paresis may
develop
Common in individuals with bulimic
behavior or psychogenic vomiting and
use or abuse of diuretics; laxative
abuse may contribute; can be life-
threatening
Chloride Elevation Chloride tends to increase to
compensate for lower bicarbonate

Decrease Binging–purging behavior and

repeated vomiting may be causes
Bicarbonate Elevation Causes may be binging and purging in
eating disorders, excessive use of
laxatives, or psychogenic vomiting

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Decrease
Decrease may develop in some
patients with hyperventilation
syndrome and panic disorder
Renal Function Tests
Blood urea nitrogen Elevation Increase is associated with mental
(BUN) status changes, lethargy, and delirium
Cause may be dehydration

Potential toxicity of medications

cleared via the kidney, such as lithium
and amantadine, may increase
Serum creatinine Elevation Level usually does not become
elevated until about 50% of nephrons
in the kidney are damaged
Serum Enzymes
Amylase Elevation Level appears to increase after binging
and purging behavior in eating
disorders and declines when these
behaviors stop
Alanine ALT > AST Disparity is common in acute forms of
aminotransferase viral and drug-induced hepatic
(ALT)— formerly dysfunction
serum glutamic
Elevation Mild elevations are common with use
pyruvic transaminase
(SGPT) of sodium valproate
Aspartate AST > ALT Severe elevations in chronic forms of
aminotransferase liver disease and postmyocardial
(AST) —formerly infarction may develop
serum glutamic
oxaloacetic
transaminase (SGOT)
Creatine Elevations of the Muscle tissue injury is the cause
phosphokinase (CPK) isoenzyme related to Level is elevated in neuroleptic
muscle tissue malignant syndrome (NMS)

Level is also elevated by repeated

intramuscular injections (e.g.,
antipsychotics)
Thyroid Function

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Serum Decrease Hypothyroidism and nonthyroid illness

triiodothyronine (T3) cause decrease
Individuals with depression may
convert less T4 to T3 peripherally but
not out of the normal range
Medications such as lithium and
sodium valproate may suppress
thyroid function, but clinical
significance is unknown

Elevations Hyperthyroidism, T3, and toxicosis may

produce mood changes, anxiety, and
symptoms of mania
Serum thyroxine (T4) Elevations Hyperthyroidism is a cause
Thyroid-stimulating Elevations Hypothyroidism—symptoms may
hormone appear very much like depression
except for additional physical signs of
(TSH or thyrotropin) cold intolerance, dry skin, hair loss,
bradycardia, and so on
Lithium—may also cause elevations

Decrease Considered nondiagnostic—may be

hyperthyroidism, pituitary
hypothyroidism, or even euthyroid
status

After completing the assessment, the nurse analyzes all the data that he or she has
collected. Data analysis 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 a particular nursing diagnosis. No
one statement or behavior is adequate to reach such a conclusion. The nurse must also
consider the congruence of all information provided by the client, family, or caregivers, as
well as his or her observations. It is not uncommon for the client’s perception of his or her
behavior and situation to differ from that of others. Assessments in various areas are
necessary to support nursing diagnoses such as chronic low self-esteem or ineffective
coping. 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, evaluating treatment effectiveness, discharge planning, and
follow-up care in the community (Videbeck, 2020).

Chapter 2 Lesson 1: Assessment

Instructional Module in NCM 117a (Care of Clients with Maladaptive Patterns of Behavior, Acute and
Chronic) | 28

ACTIVITY 4. Considering your learning at this point, describe briefly

the purposes of the psychological tests and diagnostic and
laboratory examinations performed among clients with mental
disorders.

Submit your output for this activity in the submission folder 4 of this lesson.

WRAP-UP ACTIVITY. Summarize the different assessment methods used in

assessing clients with mental disorders. Include in the summary Gordon’s
functional health patterns, psychosocial assessment, and other assessment
methods and tools.

This ends our discussion in lesson 1. Check your understanding of the

topics by answering the 30-item short quiz in the learning management
system (LMS) of this course. Feedback will be given after the
examination is closed.

Good luck!

Chapter 2 Lesson 1: Assessment

Instructional Module in NCM 117a (Care of Clients with Maladaptive Patterns of Behavior, Acute and
Chronic) | 29

References

Bisconer, S. W., & Ahsan, S. Z. (2017). Intellectual disability. Reference Module in

Neuroscience and Biobehavioral Psychology. doi:10.1016/b978-0-12-809324-5.05172-
5
Boyd, M. A. (2018). Psychiatric nursing: Contemporary practice (6th ed.). Wolters Kluwer.

Dowding, M. (n.d.). Marjorie Gordon’s 11 functional health patterns.

[Link]
gordons-11-functional-health-patterns

Potter, P. A., Perry, A. G., Stockert, P. A. ,& Hall, A. M. (2013). Fundamentals of nursing (8th
ed.). Elsevier Mosby.

Townsend, M. C. (2011). Essentials of Psychiatric Mental Health Nursing: Concepts of care in

evidence-based practice (5th ed.). F.A. Davis Company.

Videbeck, S. L. (2017). Psychiatric mental health nursing (7th ed.). Wolters Kluwer.

Videbeck, S. L. (2020). Psychiatric mental health nursing (8th ed.). Wolters Kluwer.

Chapter 2 Lesson 1: Assessment