Three kinds of assessment exist: comprehensive, focused, and screening assessments. A comprehensive assessment includes data related to the client’s biologic, psychological, cultural, spiritual, and social needs. This type of assessment is generally completed in collaboration with other health care professionals such as a physician, psychologist, neurologist, and social worker. A physical examination is performed to rule out any physiologic causes of disorders such as anxiety, depression, or dementia. For example, more than 30% of clients with dermatologic diseases have reported the presence of depressive and anxiety disorders. Neuroimaging has been included as part of a comprehensive assessment to avoid misdiagnosis or a serious delay in the diagnosis of some psychiatric disorders. It has been used to confirm psychiatric diagnoses in clients who exhibited auditory hallucinations, symptoms of bipolar disorder, behavioral symptoms of acute onset dementia, and atypical headache symptoms (Johnson, 2005; Novick, 2004; Romano, 2004; Wright, 2005). Many psychiatric facilities require a comprehensive assessment, including medical clearance, before or within 24 hours of admission to avoid medical emergencies in the psychiatric setting.

A focused assessment includes the collection of specific data regarding a particular problem as determined by the client, a family member, or a crisis situation. For example, in the event of a suicide attempt, the nurse would assess the client’s mood, affect, and
behavior. Data regarding the attempted suicide and any previous attempts of self-destructive behavior would also be collected (see Chapter 31).

A screening assessment includes the use of assessment or rating scales to evaluate data regarding a specific problem or behavior. Although a client’s history may remain stable, his or her mental status or behavior can change from day to day or hour to hour. The psychiatric mental status examination is one type of screening assessment that can be used in a variety of locations such as the emergency room, the physician’s office, or an outpatient clinic. This assessment provides a description of the client’s appearance, speech, mood, thinking, perceptions, sensorium, insight, and judgment (Sadock & Sadock, 2003). Other examples of screening assessments or rating scales used to evaluate data regarding a particular problem or behavior include the Folstein Mini Mental State Examination, Brief Psychiatric Rating Scale (BPRS), Dementia Rating Scale, Drug Attitude Inventory (DAI-10), Impulsivity Scale, or the Hamilton Rating Scale for Depression (HRSD).

Although rating scales provide useful symptom frequency and severity data, client reliability and credibility are reasonable concerns. However, the rating scales can provide objective information about clients in a variety of situations and help confirm the diagnosis of a psychiatric disorder (Menaster, 2004). For example, a screening assessment using the Abnormal Involuntary Movement Scale could be utilized to evaluate the frequency and severity of a client’s movement disorder during administration of neuroleptic medication to stabilize clinical symptoms of schizophrenia.

During any assessment, the psychiatric–mental health nurse uses a psychosocial nursing history and assessment tool to obtain factual information, observe client appearance and behavior, and evaluate the client’s mental or cognitive status. A sample psychosocial nursing history and assessment form is shown in Figure 9-2. Examples of assessment tools or screening instruments used to diagnose specific psychiatric disorders are discussed in the appropriate chapters of Units VI and VII.

According to the 2000 census, more than 6.8 million Americans identified themselves as multiracial such as
white/other, white/Native American, white/Asian, white/black, Asian/other, black/other, and three or more races. Cultural competence experts realize that nurses cannot learn the customs, languages, and specific beliefs of every client they see. But the psychiatric–mental health nurse must possess sensitivity, knowledge, and skills to provide care to culturally diverse groups of clients to avoid labeling persons as noncompliant, resistant to care, or abnormal. For example, the act of suicide is accepted in some cultures as a means to escape identifiable stressors such as marital discord, illness, criticism from others, and loneliness (Andrews & Boyle, 2003).

Several client cultural assessment approaches, identified by Mackey-Padilla (2005) and Kanigel (1999), can be used during the assessment and treatment of diverse client populations. These approaches are:

Talking openly and communicating with the client can provide valuable information about compliance and behavior. Acknowledging that differences do exist is the most important thing that the psychiatric–mental health nurse can do. Refer to Chapter 4 for more detailed information about cultural competence of the psychiatric–mental health nurse.

General appearance includes physical characteristics, apparent age, peculiarity of dress, cleanliness, and use of cosmetics. A client’s general appearance, including facial expressions, is a manner of nonverbal communication in which emotions, feelings, and moods are related. For example, people who are depressed often neglect their personal appearance, appear disheveled, and wear drab-looking clothes that are generally dark in color, reflecting a depressed mood. The facial expression may appear sad, worried, tense, frightened, or distraught. Clients with mania may dress in bizarre or overly colorful outfits, wear heavy layers of cosmetics, and don several pieces of jewelry.

Affect is defined as an individual’s present emotional responsiveness. It is the observable manifestation of one’s emotions or feelings inferred from facial expressions (eg, anger, sadness, or happiness). For example, when complemented by his teacher a child smiles. He is expressing an affective or emotional response to the complement. (The terms affect and emotion are commonly used interchangeably.) Mood is a descriptive term that refers to the presence of pervasive and sustained
emotions or feelings described by a person (Sadock & Sadock, 2003; Shahrokh & Hales, 2003). For example, a woman who cries frequently and says she misses her deceased husband who died last month, is exhibiting a depressed mood. The relationship between one’s affect and mood is of particular significance. The term congruent is used to describe consistency between a person’s affect and mood (eg, “The client’s affect is congruent with his mood.”). Conversely, affect can be widely divergent or incongruent from what one says or does. For example, a client may appear happy in the presence of family members but, when alone, abuses alcohol in an attempt to alleviate a depressed mood. Apathy is a term that may be used to describe an individual’s display of lack of emotion, interest, or concern.

A lead question such as “What are you feeling?” may elicit such responses as “nervous,” “angry,” “frustrated,” “depressed,” or “confused.” Ask the person to describe the nervousness, anger, frustration, depression, or confusion. Is the person’s emotional response constant or does it fluctuate during the assessment? When performing the interview, always record a verbatim reply to questions concerning the client’s mood and note whether an intense emotional response accompanies the discussion of specific topics. Affective responses may be appropriate, inappropriate, labile, blunted, restricted or constricted, or flat. An emotional response out of proportion to a situation is considered inappropriate. The lack of an affective response to a very emotional event may also be considered inappropriate, such as no display of emotion when discussing a close relative’s death or when discussing another traumatic event. Box 9-1 describes the various affective responses.

Under ordinary circumstances, a person’s affect varies according to the situation or subject under discussion. The person with emotional conflict may have a persistent emotional reaction based on this conflict. As the examiner or observer, identify the abnormal emotional reaction and explore its depth, intensity, and persistence. Such an inquiry could prevent a person who is depressed from attempting suicide.

Asking about suicidal risk, violent behavior, or substance abuse during client assessments is embarrassing for many nurses. Such embarrassment may result in the nurse’s judging a client or making assumptions about the client (Blair, 2005). To avoid such mistakes when assessing clients’ behavior and attitude, consider the following factors:

If clients are in contact with reality and able to respond to such a question, ask them how they normally cope with a serious problem or with high levels
of stress. Responses to this question enable the nurse to assess clients’ present ability to cope and their judgment. Is there a support system in place? Are clients using medication, alcohol, or illicit drugs to cope? Their behavior may be the result of inadequate coping patterns or lack of a support system.

Clients experiencing paranoia or suspicion may isolate themselves, appear evasive during a conversation, and demonstrate a negativistic attitude toward the nursing staff. Such activity is an attempt to protect oneself by maintaining control of a stressful environment.

“The manner in which the client talks enables us to appreciate difficulties with his thought processes. It is desirable to obtain a verbatim sample of the stream of speech to illustrate psychopathologic disturbances” (Small, 1980, p. 8).

The client may hesitate to communicate with a complete stranger on the first meeting unless the nurse is able to display empathy for the client’s distress and establish trust with the client. Consider the following factors while assessing clients’ ability to communicate and interact socially:

A review of data collection enables the nurse to integrate specific purposeful communication techniques during interactions with the client. These techniques are chosen to meet the needs of the client and may be modified based on their effectiveness during the nurse–client interaction (Schultz & Videbeck, 2005).