Classification systems provide a functional, standardised and validated means of grouping objects or phenomena (Weir & Oie 1996). A mental health professional classifies mental disorders according to patterns of behaviour, thought and emotion. Research has led to the development of a universal system of classifying mental disorders: the Diagnostic and Statistical Manual of Mental Disorders, 4th edition (text revision) (DSM-IV-TR) (American Psychiatric Association 2000) and the International Statistical Classification of Diseases and Related Health Problems (ICD-10-AM) (WHO 1992).

An understanding of classification systems enables mental health nurses to communicate effectively and professionally with other health disciplines, to participate collaboratively in client care, to contribute to clinical research, and to organise and use data in clinical problem solving and in choosing effective interventions (Clinton & Nelson 1996). McMinn (1995) discusses the dilemma of having two classification systems when working in multidisciplinary teams—that is, the nursing diagnostic system (which is used in some settings) and the more widely accepted classification systems for mental disorders, the DSM-IV-TR and the ICD-10-AM. The Australian National Standards for Mental Health (Australian Health Ministers National Mental Health Working Group 1996) advocate the introduction of universally accepted classification systems, which will be discussed in this chapter.

Assessment

Assessment is the first step in the diagnosis of mental disorders. A mental health assessment ‘is a complex intellectual activity that includes formulating hypotheses about a person, deciding what data are necessary to confirm or disconfirm these hypotheses, gathering the required data, interpreting them and finally drawing conclusions’ (Schwartz 2000, p 96). Mental health assessment occurs in conjunction with a full clinical assessment: ‘clinical assessment is the systematic evaluation and measurement of psychological, biological, and social factors in an individual presenting with a possible psychological disorder’ (Barlow & Durand 2005, p 69).

A broader definition of assessment is:

gathering, classifying, categorising, analysing and documenting patient information about health status. It starts with the process of establishing a therapeutic alliance between the patient and/or client and the mental health worker and forms the basis of care planning. The process of assessment should be approached with empathy and compassion to support the development of trust between the patient and/or client and the mental health worker (NSW Health 2001, p 21).

Performing thorough, accurate and ongoing assessment is a major part of the role of the mental health nurse. Assessment is a complicated process, as the diagnosis arrived at from assessment determines the treatment for the person presenting with a mental health problem. A thorough assessment gives the opportunity to gauge consumer strengths as well as needs.

Assessment rarely involves one function. We might assess people to find out who they are, to describe and measure specific problems of living, or to describe their assets and personal and social resources (Barker 2003a). A comprehensive assessment involves all of these. Through assessment it is hoped that we gain some understanding of meaning and human significance of the person’s problem (Barker 2003a)

Assessment can be formal or informal. A formal assessment has an organised interview plan and uses tools such as checklists, questionnaires and rating scales to obtain relevant information to assist with the assessment interview. An informal assessment has less structure and questions are asked that the interviewer believes are relevant at the time. Barker (2003a) states that the formal interview has advantages over the informal interview as the tools and structured interview plan means that people are assessed in more or less the same way. He states that our biases, opinions and other ‘value judgments’ are less likely to influence the interview, as can occur in an informal assessment. The choice of formal or informal assessment methods is determined by the person in care and the standardised assessment protocols that the mental health services have adopted.

In Australia, The National Mental Health Policy (Australian Health Ministers 1992), National Standards for Mental Health (Australian Health Ministers National Mental Health Working Group 1996), and the National Mental Health Plan 2003–2008, building on the first and second National Mental Health Plans (Australian Health Ministers 2003) all emphasise the importance of a thorough and comprehensive assessment for con sumers accessing mental health services. Standard 11.3 of the National Standards relates to assessment and review, and provides criteria for mental health services to ensure that consumers and carers receive a com prehensive, timely and accurate assessment with a regular review of progress (Australian Health Ministers National Mental Health Working Group 1996). A summary of the criteria for achieving this standard is provided in Box 11.1.

Box 11.1 Criteria for national standards of assessment

• Assessments are conducted by appropriately qualified and experienced mental health professionals.

• Assessment is conducted wherever possible in settings chosen by the consumer, considering the safety of mental health staff and the consumer.

• The mental health system follows up appropriately those who decline to participate in assessment.

• Assessment records are commenced during the first contact with the service.

• Assessment is comprehensive and includes the carers and other people involved with the consumer, with the consumer’s consent.

• Assessment is conducted using accepted methods and tools.

• Documented protocols and procedures within the mental health system describe the assessment process.

• Assessment is recorded in an individualised clinical record in a timely and accurate manner.

• There is an opportunity for the assessment to be conducted in the preferred language of the consumer and their carers.

• Assessment is conducted with sensitivity to cultural and language issues which may affect assessment.

• Diagnosis is made using international standards by an appropriately qualified and experienced mental health professional.

• Consumers and carers, with the consumer’s consent, are provided with information on diagnosis, options for treatment and possible prognoses.

• Assessment by telephone and video technology is acceptable where face-to-face contact is not possible due to distance or the consumer’s preference.

• Assessments are continually reviewed throughout the consumer’s contact with the service.

• New assessments are subject to clinical review by the mental health service.

• All active consumers are re-assessed and reviewed every three months by a multidisciplinary team and recorded in the individual’s clinical record.

• Staff of the mental health service involved in assessment undergo specific training in assessment and receive supervision from a more experienced colleague.

Source: Australian Health Ministers National Mental Health Working Group 1996, p 31.

In accordance with these standards, mental health services have developed standardised assessment protocols which staff in all health disciplines are familiar with and have been trained in. The assessment of clients presenting to mental health services is standardised across all disciplines, with corresponding accurate documentation. For example the NSW Mental Outcomes and Assessment Training Tool (NSW Health 2001) provides a standard format for documentation, with a set of expectations including:

• the domains covered in assessments and care plans at triage

• comprehensive clinical assessments

• review during ongoing care and discharge planning

• how these assessments should be recorded in the medical record

• routine outcome measures.

This direction in mental health services results in all health disciplines performing and documenting a standard mental health assessment that provides clear communication for all those involved in a person’s care.

Assessment methods

The aim of assessment is simple but the process is complex. We aim to answer the question ‘What is really going on here, and how will this help us work out what we need to do, by way of a caring response?’ (Barker 2003b, p 66). Information about people can be collected in two ways: by the person themselves, or by other people who have observed the person’s behaviour, such as family and carers or the person’s treating team. What we need to know about the person will determine how we gather the information. If we need to know how a person thinks or feels, or their values and beliefs, we need to ask the person. If we need to know what other people think, feel or believe about the person, we need to ask those other people. If we need to know how a person might behave in certain circumstances, we ask the person to observe or reflect on their behaviour, or we ask someone to observe the behaviour, or both (Barker 2003b). Understanding the lived experience of consumers and carers is essential to assessment. Information essential for understanding the lived experience includes the consumer’s or carer’s way of interpreting or understanding what is happening to him or her, in addition to knowledge about the person’s life, including how previous aspirations and plans, personal and social resources and circumstances are affected by what is happening (Fossey 2007). Leggatt (2007) states that family members and significant others should be engaged with the treating staff as early as possible because they have in-depth information about the development of the symptoms and also knowledge of the social and emotional environments that may contribute to the symptoms. The family and significant others can also provide information about the person’s interests, abilities and personality characteristics.

Barker (2003b) has identified four major assessment methods:

• interviewing

• diaries and personal records

• questionnaires and rating scales

• direct observation.

Essential nursing skills

The assessment process is the first step in developing a therapeutic nurse–client relationship. The therapeutic relationship ‘represents a time-bound alliance between the nurse and client which is consciously entered into’ (Carson 2000, p 202). This relationship depends on communication skills, the most important being empathy and presencing.

Empathy represents a mutual interpersonal process in which the nurse is able to capture the inner struggle of the patient, bring together different aspects of the patient’s situation in a meaningful way, and communicate that understanding in a way that is understood as truth by the patient (Zderad 1969, cited in Carson 2000, p 217).

Egan has expressed empathy in the following stylised formula:

You feel … (name the correct emotion expressed by the client) … because or when … (here indicate the correct experiences and behaviours that give rise to the feelings (Egan 1998, p 83).

This formula allows the client to feel heard and understood. ‘Presencing’ has been defined as ‘attempting to be non-judgmental and non-defensive while creating a conducive environment for an open constructive conversation and allowing the experience of the client to affect you’ (Glass 2003, p 55). Glass also states (p 55) that ‘presencing concerns a head and heart shift; it involves suppressing your own concerns and moving from your own space/happenings to the client’s space/ happening’. As such, presencing involves ‘being in the moment’ with the client and giving your undivided attention. This skill has also been referred to as immediacy (refer to Ch 23).

Chapter 23 addresses the communication skills that are needed to achieve empathy and immediacy when interviewing a client. The following issues also need to be considered:

• Location of the interview—where possible the nurse should interview the client in a location where the client’s dignity, privacy and comfort are respected. A quiet, private setting where client and nurse can interact at eye level provides the structure for the formation of a therapeutic alliance.

• Client’s developmental stage—major crises that occur in life are often related to the transition required through each stage. For example, is a young mother’s depression related to the transition from ‘independent’ career woman to ‘dependent’ mother? Is the sixteen-year-old’s antisocial behaviour related to the transitional period of childhood to adolescence? A developmental perspective can assist the nurse in understanding the client’s perspective (refer to Ch 9).

• Apprehension in the client—most people presenting for assessment are fearful or confused about symptoms they have experienced. They may also be embarrassed about the stigma surrounding mental illness. In addition, some believe that professionals working in mental health can ‘read’ people’s minds or at least have remarkable powers of insight into the individual. Some inexperienced nurses are apprehensive about communicating with people with a mental disorder. Being aware of the client’s apprehension may facilitate understanding of the problem.

• General questions first, then specific—the nurse should take a broad, holistic approach at the beginning of the interview. The first three to ten minutes should be the most open-ended of the interview. Using open-ended questions will help the client to begin to feel respected and listened to, and be more willing to focus on specific issues. The nurse’s responses during the initial assessment phase should be focused on building rapport, and should consist of empathic silences, repeating the client’s last words, identifying the client’s affect (‘That must have made you very sad’) and requesting clarification.

As the nurse begins to develop an overall picture of the client, questions become more specific and direct: ‘Tell me more about this depression, Mr Jones’.

As the assessment interview progresses, the nurse should ask more focused questions: ‘How long have you been feeling that life is hopeless?’, ‘How many kilos have you lost in the past month?’ At this stage of the interview the nurse is trying to collect information related to when the symptoms appeared, whether they have been getting better or worse, what the symptoms are like, how severe they are and their relation to other symptoms. Collecting this information enables the nurse to formulate a diagnosis related to diagnostic criteria for specific mental disorders.

Finally, the nurse should focus on closed questions—that is, questions with a yes or no answer: ‘Have you ever had blackouts?’, ‘Have you found yourself thinking that everyone is against you?’

The development of interviewing skills will ensure that the nurse and the client can enter into a therapeutic relationship where problems are identified and a plan of care is established.

The craft of interviewing

Barker (2003c) speaks of the craft of interviewing. People know who they are through their stories. Barker (2003a) talks of the background of human identity: the stories that people are born into and become part of, through the telling of their story. The story involves more than the events a person experiences; the background stories are important as they frame the developing script of the story of the person here and now. Therefore, in an assessment interview it is important to ask, ‘Who is this person?’. In this way you cannot divorce the person from all the stories that shaped the person’s life story (Barker 2003a). Barker (2003a) emphasises the importance of knowing why we do an interview. He believes our motto should be ‘to seek first to understand’ (p 65). To begin to understand, we are required to examine the situation with the person and enquire into their experience of what is happening. Then we need to understand why we have chosen one approach over another. But most importantly we need to understand how little we know about the person we are interviewing, and seek to understand through our interview something of value about the person and their experience (Barker 2003a).

No assessment can be expected to succeed without basically sound interview techniques (Meadows 2007c). Inadequate assessment will result in inadequate care (Barker 2003a). The goal of interviewing is to collect as much relevant information as possible by the shortest route, and in this, the questions and how they are asked is of importance (Barker 2003c).

An interview can be an uncomfortable experience for the person and may promote anxiety. People may disguise their anxiety through hesitant answers, short replies or apparent striving to please. Appropriate questioning can reduce this. An important question that should be asked at the beginning is: ‘Do you want to ask anything before we begin?’. Other simple questions such as ‘What have you brought along with you today?’ or ‘What brings you here?’ give the person a chance to influence the direction of the interview and foster a sense of partnership (Barker 2003c).

Meadows (2007c) provides the following strategies for encouraging a person to share their feelings later in the interview, after neutral information about them (such as age, address and occupation) has been collected:

• Put down your pen.

• Adopt a posture that has some echo of the client’s, providing an obvious physical expression of empathy, and perhaps telling you something about what it feels like to adopt his or her posture.

• Allow a few moments of non-threatening eye contact, and a few short moments of silence, including silencing of your own internal mental chatter.

• Note your impression of the interaction and your empathic sense of how the client feels, as well as how you feel.

• Follow up this non-verbal initiative with a gentle but direct ‘How are you?’—this may yield more information in a minute than an hour spent in ways that are less likely to convey to the client the impression of being an empathic and concerned fellow human being (Meadows 2007c, p 286).

Interviewers need to be non-judgmental: in some situations people may make statements that are disturbing, such as admissions concerning suicide intent, sexual practices, past misdeeds that have inspired guilt, or material considered bizarre or delusional. An expression of surprise, astonishment, reproach or even stunned silence will stifle any further admission or self-examination (Barker 2003c).

The concept of resistance is used to explain difficulties with the interview process. Barker (2003c) believes that, to prevent resistance developing, we should see the interview from the person’s perspective. He provides the following solutions for obstacles which may occur during the interview:

• Failure to respond—the person does not give the information asked for in the interview. This could be the result of a poorly phased question, so try presenting the question in a different way.

• Difficulty answering the question—the person may answer but be unsatisfied with their reply. Offer some words of encouragement and provide discrete feedback to help the person find the words they need to explain the situation.

• Refusal to answer—try rephrasing the question, or nudging the person gently. Or respect the person’s wishes and leave this issue for another time and place. Always let the person know why you have postponed the question.

• Going off on a tangent—one question can produce a number of answers, some relevant, some less so. The interviewer must decide whether to respond to some of these tangents or stick to the core question. Turning the decision over to the person as to whether they wish to discuss these tangents empowers the person’s decision-making. It is important to gauge the flow of the conversation carefully (Barker 2003c, pp 81–2).

Critical thinking challenge 11.1

Horsfall, Stuhlmiller & Champ (2000) suggest the following exercise to sensitise you to the words used in practice and their associated meaning for distancing or labelling a client. This exercise can be conducted alone or with other mental health professionals in the clinical setting.

In a notebook or on a piece of paper, write down all the key words you hear used by mental health professionals in describing the communication or actions of clients.

After you have generated an extensive list, which could take several days to compile, do the following:

Count the frequency of each word on any given day.

Look up the dictionary definition of each word. Does the dictionary definition of the word match the meaning intended by the mental health professional who used it?

Think about how you might determine whether there is a discrepancy between the dictionary definition and the word as used by the mental health professional.

Evaluate the usefulness of each word as it is expressed. How does it open up or close off understanding of the person?

Decide whether there are any words that should be eliminated or replaced with terms that would more accurately depict observations.

Source: Horsfall et al 2000, p 87.

The interview setting

Sometimes a key determinant of how the assessment will be conducted is where it occurs (Meadows 2007b). A person can be interviewed in their bedroom on the ward, the sitting room at home, a consulting room off the ward, or an interview room at the clinic (Barker 2003c). Meadows (2007b) states that the place in which a person is interviewed influences the power relationship of the interview and the actions that might follow. For example, in a family home, the assessor has been invited into the home, which gives control to the family members there. A difficulty with this is that the interviewer may be influenced by the dominant member of the family and it may be difficult for other members of the family to express their views.

Sole dwellings or bed sits are common types of accommodation for people living with a mental disorder. Often this accommodation has limited support structures and is a problematic environment in a practical sense. As such the person’s living skills may be modified and well attuned in order to survive in this type of accommodation. A functional assessment of the person’s living skills will need to take this into consideration. In contrast, institutions provide high levels of support and basic needs, so a person’s functional level may not be rated as high because the institution is providing for the person. In addition, privacy may be limited during the interview. People living on the street have very little privacy and their social networks are often broken. The person needs high levels of coping skills in order to survive in such an environment. If a person is creating a public disturbance, the mental health worker may feel pressured to label the person as mentally ill, as this provides resolution of the problem. Assessment may be made difficult by the inability to secure privacy, pressure on time, and other uncontrolled interventions by members of the public. Responsibilities may be unclear and negotiations about these responsibilities to other groups, such as the police, may be difficult and complex (Meadows 2007b).

Primary care settings provide similar features to public places. General practice clinics provide mental health services, but given the nature of the setting they can be problematic, as the setting and time constraints may limit assessments. If mental health workers are required to conduct assessments in such settings they need to be aware of their status as guests. It is often helpful to have an understanding of the dynamics of the particular practice, including the reactions of the administrative and reception staff. Medical care facilities include hospitals, accident and emergency departments and inpatient settings. The power relationship is skewed towards the mental health worker as the client is in less familiar and possibly threatening territory. Finally, assessment may be conducted at the police station, remand centre or prison. Such settings have their own particular rules and hierarchies. Awareness of the legal context in which the interview is being conducted is important in understanding the person’s situation. The mental health worker needs to establish the purpose of the interview and the limitations of the assessment interview within this legal context (Meadows 2007b).

Safety

Most people with mental health problems present no risk of violence. On most occasions where violence does occur, the violence has been anticipated. Sensible precautions minimise the risk to the mental health worker.

Meadows (2007b) provides key points for mental health workers to follow, to ensure their safety:

• Be aware of the need to anticipate violence, and don’t ignore the presence of weapons, threats, cues that the person is angry, or a history of violent behaviour.

• Be prepared to involve the police—for instance, in disarming an armed person.

• In an assessment situation, be mindful of the availability of escape routes.

• Avoid being alone with a person unless you are confident that the risk of violence is low.

• Listen to your intuitive and emotional responses to the situation, and be open to acting on them. Be prepared to escape from a situation in which you feel threatened, or call for help.

• Be clear about the limits of tolerable and acceptable behaviour in the assessment context. For instance, be prepared to insist that the person being assessed is not armed. Be prepared to terminate the interview, possibly abruptly, on the grounds of concern for your safety.

• On occasions, it may be important to acknowledge the existence of violent impulses that the client may have, but not necessarily be frightened of them. However, do not confuse this with bravado or machismo.

• Successful restraint requires enough (often at least five) properly trained people.

• Avoid presenting as threatening to the person being assessed. Paranoid people are often violent because they are frightened.

• Administering sedative drugs, particularly intramuscularly and intravenously, in a setting without full medical support has been associated with fatalities and is to be avoided (Meadows 2007b, p 287).

In addition to these key points, the following strategies can help provide a safe assessment setting in the event that the mental health worker feels threatened:

• Multiple exit routes with outward opening doors can prevent the mental health worker being trapped in a room.

• Spaces without movable furniture which can used to blockade doors are preferred.

• Potential weapons should be considered and removed.

• The mental health worker carries a concealed personal alarm system.

• Arrangements are made to provide backup staff if there is potential for violence during an interview (Meadows 2007b, p 288).

Biopsychosocial model of assessment

A biopsychosocial assessment involves a comprehensive assessment of all aspects of the client’s problem—biological, psychological, sociological, developmental, spiritual and cultural—with information derived from interviews with the client and their family, or others as appropriate. Concerns need to be addressed regarding how they may have led to the illness developing and how they may be maintaining the problem behaviour for the client (Onyett 1998).

Assessment is completed with all clients, regardless of the setting. The forms used and details sought may vary, but the principal information gathered is similar. Broadly speaking, the information gathered in an assessment interview provides the framework for a comprehensive biopsychosocial assessment of the client’s current presentation to mental health services.

When assessing a person for the first time, information needs to be gathered in order to answer the following questions:

• Does the person have a mental health problem? If so, what is the problem?

• What is the most suitable treatment for the individual?

• Can the team provide appropriate treatment? If not, to whom can the individual be referred?

• If the individual is accepted for treatment, are there concurrent social or health problems that need urgent attention before psychiatric treatment commences?

• What effect might the intervention have on the individual’s health status? (adapted from Treatment Protocol Project 2004, p 8) Other issues to consider include:

• access—how will you best be able to gain access to this person?

• engagement—are there factors which may make it difficult for you to engage with the person?

• rapport—how best might you build a therapeutic alliance with this person?

• location—is the location of the assessment conducive to good communication? Do you have adequate support in case of problems?

• local protocols—are you aware of local policies and protocols governing suicide assessment and management?

• local resources—are you aware of local resources that could be used to manage a person’s risk?

• existing information—have you checked for any existing information available about this person? (NSW Health 2001, p 60).

Psychiatric assessment

The purpose of the psychiatric assessment is to develop an understanding of the person presenting for help. It involves taking a basic psychiatric history and a mental status assessment. The following information is required in conducting a comprehensive psychiatric assessment:

• identifying information

• reason for referral

• presenting problem and/or precipitating factors

• previous mental health history/medical history/drug history

• developmental/psychosocial/ relationship history

• risk factors

• assessment of strengths

• assessment of mental health status.

Identifying information

Identifying information includes: name, age, sex, present address, telephone number, languages spoken, general practitioner, marital status, occupation and next of kin. Some forms will require additional information about children, education level attained and family of origin, for example.

Example

Mary Jones is 32 years old, married, with four children, lives at 22 Brown St, telephone number 8888 888. She speaks English and is working part time in a real estate office. Her regular GP, Max Smith, is aware of her coming to the Cowan Mental Health Clinic today.

Presenting problem

Obtain a brief description of the principal complaint and the time frame in the client’s own words. Listening to the client facilitates the development of a therapeutic alliance.

You will need to obtain the following information:

• specific symptoms that are present and their duration

• time relationships between the onset or exacerbation of symptoms and the presence of social stressors/physical illness

• any disturbance in mood, appetite, sexual drive or sleep

• any treatments given by other doctors or specialists for this problem

• the individual’s response to treatment.

The following narratives provide examples of how the mental health nurse can maximise the quality of information obtained.

First, determine the consumer’s perception of the situation.

Example

Nurse:	Mary, Dr Smith asked me to see you today because he is concerned about some of the things you have been saying and doing. Can you tell me what you think has been going on?
Mary:	I have been feeling really confused and upset for the last few months and just not right.
Nurse:	What are some of the things that may be making you feel just not right?
Mary:	I don’t seem to be able to cope with everyday living and lately I have been hearing voices, which are really upsetting me.
Nurse:	How are the voices upsetting you?
Mary:	They are in my head all the time and they keep telling me to kill myself. It’s horrible.

Second, get an overview of the precipitating factors/events. Ensure that the chronology of the events and the emergence of the symptoms is clear. The context of the presenting problem is also important. Box 11.2 details the social and environmental precipitating events that may have triggered the episode or be maintaining the behaviour.

Box 11.2 Precipitating environmental and social problems

• Problems with primary support: death of family member, health problems in family, disruption of family by separation, divorce or estrangement, removal from home, remarriage of parents, sexual or physical abuse, parental over-protection, neglect of child, inadequate discipline, discord with siblings, birth of siblings. Note: In most states, reporting of suspected child abuse is mandatory for healthcare professionals.

• Educational problems: literacy, academic problems, discord with teachers and classmates, inadequate school environment.

• Occupational problems: unemployment, threat of job loss, stressful work schedule, difficult work conditions, job dissatisfaction, job change, discord with boss or co-workers.

• Economic problems: extreme poverty, inadequate finances, insufficient welfare support.

• Problems with access to healthcare: inadequate healthcare services, transportation to healthcare facilities unavailable, inadequate health insurance.

• Other psychosocial and environmental problems: exposure to disasters, war, other hostilities, discord with non-family caregivers such as counsellor, social worker or physician, unavailability of social service agencies.

(Source: adapted from NSW Health 2001, p 93.)

Example

Nurse:	How long have you been feeling ‘not right’?
Mary:	It seemed to happen soon after Jenny was born. At first, I would cry all the time and couldn’t manage any of the housework. It was really difficult trying to look after Jenny and the other kids. Sometimes I would go to bed because I just didn’t want to face the day. I thought there was something really wrong, because I wasn’t sleeping or eating and I kept getting headaches, muscle aches and pains and an upset stomach. I have been seeing Dr Smith a lot, hoping he could fix me up.
Nurse:	When was Jenny born?
Mary:	June the 18th. She will be three months old tomorrow.
Nurse:	You said you told Dr Smith about the voices this morning. Have the voices been bothering you ever since you felt not right, after Jenny was born?
Mary:	No, the voices only started about a month ago, but they are getting worse and I don’t know what to do. It feels like I’m going mad.

The nurse would have to ask more open-ended questions to determine whether any other social or environmental problems may have precipitated or be contributing to the problem.

Mental health/medical/drug history

Mental health history

Information required includes the number of admissions to mental health inpatient units, number of episodes of self-harm, attempted suicide or occasions of assault, and an indication of any mental health treatments received. This information is usually obtained from the client, previous clinical notes, a letter from the doctor, or history provided by relatives or friends.

Example

Nurse:	Mary, what you are experiencing must be pretty scary. Has this ever happened before?
Mary:	No, this is the first time I have ever felt like I have been going mad and the voices really frighten me.
Nurse:	What about after the other three kids were born. How did you feel then?
Mary:	I had no problem at all. Everyone has always said how together I am. That’s why this is really freaking me out.

Medical history

Information includes major medical and surgical history. If relevant, the client’s consent should be sought to obtain a detailed medical history from the treating doctor.

Example

Nurse:	Have you ever been in hospital for an operation or a medical complaint?
Mary:	No, I was just in hospital for the birth of the kids. The last one was pretty tiring and hard.
Nurse:	Did you have any medical problems after the birth?
Mary:	No, I just have long births and lots of pain.
Nurse:	Do you have any physical problems for which the doctor is treating you?
Mary:	No, apart from the last three months with the headaches and stomach aches.
Nurse:	To help us obtain a better picture of your health, will you give us your consent to obtain information from your doctor if we need to?

Only gold members can continue reading. Log In or Register to continue

Stay updated, free articles. Join our Telegram channel

Tags: Psychiatric Mental Health Nursing

Feb 19, 2017 | Posted by admin in NURSING | Comments Off

Nurse Key

Fastest Nurse Insight Engine

Assessment and diagnosis

Introduction

Classification systems

Assessment

Assessment methods

Interviewing

Diaries and personal records

Questionnaires and rating scales

Direct observation

Essential nursing skills

The craft of interviewing

The interview setting

Safety

Biopsychosocial model of assessment

Psychiatric assessment

Identifying information

Example

Reason for referral

Example

Presenting problem

Example

Example

Mental health/medical/drug history

Mental health history

Example

Medical history

Example

Related

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree

Fastest Nurse Insight Engine

Assessment and diagnosis

Share this:

Related

Related posts:

Stay updated, free articles. Join our Telegram channel

Full access? Get Clinical Tree