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Comprehensive 20 Assessment 1

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Comprehensive Mental Health Assessment

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Comprehensive 20 Assessment 1

  1. 1. Comprehensive assessment in Mental Health nursing
  2. 2. What is Assessment ? <ul><li>‘ gathering, classifying, categorising, analysing, and documenting information about health status. It starts with the process of establishing a therapeutic alliance between the patient 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/ client and the mental health worker.’ </li></ul><ul><li>(NSW Health, 2001) </li></ul>Elder et al, 2005
  3. 3. Comprehensive clinical assessment <ul><li>Biological </li></ul><ul><li>Psychological </li></ul><ul><li>Sociological </li></ul><ul><li>Developmental </li></ul><ul><li>Spiritual </li></ul><ul><li>Cultural </li></ul>Elder et al, 2005
  4. 4. Information required <ul><li>Identifying information </li></ul><ul><li>Reason for referral </li></ul><ul><li>Presenting problem and/or precipitating factors </li></ul><ul><li>Previous mental health/ medical/ medication history </li></ul><ul><li>Developmental/ psychosocial/ relationship history </li></ul><ul><li>Risk Factors </li></ul><ul><li>Assessment of strengths </li></ul><ul><li>Assessment of mental health status </li></ul>Elder et al, 2005
  5. 5. Identifying information <ul><li>Name, age , sex, marital status, present address, telephone number </li></ul><ul><li>Languages spoken </li></ul><ul><li>Occupation </li></ul><ul><li>Next of kin </li></ul><ul><li>G.P. </li></ul>Elder et al, 2005
  6. 6. Reason for referral <ul><li>Who has asked for the patient to be seen and why </li></ul><ul><li>The nature of the problem </li></ul><ul><li>Events that led to this presentation </li></ul><ul><li>Any recent suicide attempts </li></ul><ul><li>Any recent episodes of self harm </li></ul>Elder et al, 2005
  7. 7. Presenting problem <ul><li>Present specific symptoms and duration; </li></ul><ul><li>Time frame between onset and exacerbation of symptoms and presence of social stressors / physical illness </li></ul><ul><li>Any disturbances in mood, appetite, sexual drive, or sleep </li></ul><ul><li>Any treatments given by other doctors or specialists for this problem </li></ul><ul><li>Individuals response to treatment </li></ul>Elder et al, 2005
  8. 8. Mental health/ medical History <ul><li>Mental Health History </li></ul><ul><li>Admissions to Mental Health inpatient units </li></ul><ul><li>Episodes of self harm </li></ul><ul><li>Attempted suicides </li></ul><ul><li>Occasions of assault </li></ul><ul><li>Any mental health treatments previously/currently </li></ul><ul><li>Medical History </li></ul><ul><li>Major medical and surgical history </li></ul>Elder et al, 2005
  9. 9. Medication History <ul><li>Current medications </li></ul><ul><li>Regime </li></ul><ul><li>All prescribed and non-prescribed medication </li></ul><ul><li>Dosage, frequency and prescriber </li></ul><ul><li>When last used </li></ul><ul><li>Any compliance problems </li></ul><ul><li>Adverse reactions </li></ul><ul><li>Allergies to any drugs </li></ul>Elder et al, 2005
  10. 10. Psychosocial relationship History <ul><li>Infancy </li></ul><ul><li>Childhood and adolescence </li></ul><ul><li>Work history </li></ul><ul><li>Marital history </li></ul><ul><li>Relationship with others </li></ul><ul><li>Children </li></ul><ul><li>Illegal activities </li></ul>Elder et al, 2005
  11. 11. Risk Factors <ul><li>Harm to others </li></ul><ul><li>Harm to self </li></ul><ul><li>Suicide </li></ul><ul><li>Absconding </li></ul><ul><li>Vulnerability to exploitation or abuse (Sexual or violence) </li></ul><ul><ul><ul><ul><li>Extensive documented past history of sexual abuse/ violent relationships </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Unawareness regarding dress or personal space </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Frequent /intense thoughts re sexual activity with no possibility of distraction </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Increasingly intrusive behaviour </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Evidence of hostile, dependant or passive personality traits </li></ul></ul></ul></ul><ul><ul><ul><ul><li>Evidence of substance abuse </li></ul></ul></ul></ul>Elder et al, 2005
  12. 12. Assessment of strengths <ul><li>Intelligence </li></ul><ul><li>Education </li></ul><ul><li>Support systems </li></ul><ul><li>Religious and spiritual beliefs </li></ul><ul><li>Motivation </li></ul><ul><li>Physical health </li></ul>Elder et al, 2005
  13. 13. Spiritual Assessment <ul><li>Often overlooked </li></ul><ul><li>Patients may be hesitant to talk about spiritual experiences as may interpreted as crazy </li></ul><ul><li>Need to remember that each individual has their own spiritual interpretation of universe </li></ul><ul><li>creating a comfortable safe setting is important to facilitate this form of assessment </li></ul>Elder et al, 2005
  14. 14. Physical Assessment <ul><li>An assessment of physical functions provides a baseline: </li></ul><ul><li>Elimination </li></ul><ul><li>Activity and exercise </li></ul><ul><li>Sleep </li></ul><ul><li>Appetite and nutrition </li></ul><ul><li>Hydration </li></ul><ul><li>Sexuality </li></ul><ul><li>Self-care </li></ul>Elder et al, 2005
  15. 15. Cultural Assessment <ul><li>Attitudes can interfere with appropriate assessment </li></ul><ul><li>Failure to communicate effectively can cause delays in diagnosis and treatment </li></ul><ul><li>Adoption of the underlying principles of cultural safety by nurses will enable appropriate assessment </li></ul>Elder et al, 2005