Psychosocial Assessment, Legal & Ethical Issues
Purpose – Overall View
The psychosocial assessment aims to provide an overall view of the client, delving into their psychological and social well-being to understand their current state comprehensively.
It assesses the client’s current emotional state, mental capacity, and behavioral function, providing a detailed analysis of their mental and emotional health.
It forms the basis for developing a plan of care tailored to the client's specific needs, integrating psychological and social factors for a holistic approach.
Establishes a clinical baseline to evaluate the effectiveness of treatment and measure the client’s progress, offering a benchmark for assessing improvements and adjustments in the care plan.
Influencing Factors
Client participation and feedback are crucial, requiring active involvement and honest communication from the client for an accurate and effective assessment.
The client’s health status significantly influences the assessment, as physical health conditions can impact mental and emotional well-being.
Previous experiences and misconceptions about healthcare can affect the assessment, potentially causing apprehension or skepticism that may hinder the process.
The client’s ability to understand impacts the process, necessitating clear and accessible communication to ensure the client comprehends the questions and purpose of the assessment.
The nurse’s attitude and approach play a vital role, requiring empathy, patience, and a non-judgmental demeanor to establish trust and facilitate open communication.
Interview
Environment:
Should be comfortable, private, and safe to encourage openness and honesty.
Quiet with few distractions to minimize interruptions and maintain focus.
Input from family and friends:
Gather perceptions of the client to gain additional insights and perspectives.
Recognize that information can be limited, acknowledging potential biases or incomplete knowledge.
Questions:
Use open-ended questions to encourage detailed responses and uncover underlying issues.
Employ focused questions if the client cannot organize thoughts or has difficulty answering open-ended questions, providing structure and clarity.
Assessment
History:
Age: Provides context for developmental and life-stage considerations.
Developmental stage: Identifies age-related milestones and potential developmental delays.
Cultural considerations: Recognizes the impact of cultural background on beliefs, values, and behaviors.
Spiritual beliefs: Acknowledges the role of spirituality in the client’s life and coping mechanisms.
Previous history: Examines past experiences, traumas, and mental health issues that may influence current state.
General appearance/motor behavior:
Hygiene and grooming: Assesses self-care habits and potential signs of neglect or distress.
Appropriate dress: Evaluates the suitability of attire for the setting and weather conditions.
Posture: Observes body language for signs of discomfort, anxiety, or depression.
Eye contact: Assesses engagement, attentiveness, and potential avoidance behaviors.
Unusual movements/mannerisms:
Automatisms: Repetitive, seemingly purposeless movements or behaviors.
Psychomotor retardation: Slowed physical movements and mental processes.
Waxy flexibility: Maintenance of posture or position over time, even when it is awkward or uncomfortable.
Speech:
Neologisms (newly coined word or expression): Indicates disordered thought processes and potential psychosis.
Mood/affect:
Assess for consistency between reported mood and observed affect to identify potential discrepancies.
Common terms in assessing affect:
Blunted: Reduced emotional expression.
Broad: Normal range of emotional expression.
Flat: Absence of emotional expression.
Inappropriate: Emotional expression that is incongruent with the situation or content.
Restricted: Mildly reduced range of emotional expression.
Labile: Rapidly changing emotional expressions.
Thought process/content:
Process (how the client thinks) and content (what the client says) provide insights into cognitive functioning and potential thought disorders.
Circumstantial thinking: Including unnecessary details and irrelevant information in communication, but eventually returning to the original point.
Delusion: False, fixed belief that is not consistent with reality.
Flight of ideas: Rapidly changing, fragmented thoughts.
Ideas of reference: Interpreting random events or comments as having personal significance.
Loose associations: Disconnected or illogical flow of thoughts.
Tangential thinking: Wandering off-topic and never returning to the original point.
Thought broadcasting: Belief that one’s thoughts are being transmitted to others.
Thought insertion: Belief that thoughts are being placed into one’s mind by an external source.
Thought blocking: Sudden interruption of thought process.
Thought withdrawal: Belief that thoughts are being removed from one’s mind.
Word salad: Incoherent mixture of words and phrases.
Tangential vs. Circumstantial Speech
Circumstantial Speech:
Eventually gets to the point but takes a "long spiral" way, providing excessive details and irrelevant information before returning to the main topic.
Tangential Speech:
Never gets to the point; talks completely past the point, diverging from the original topic without ever returning.
Types of Delusions
Bizarre: Imagining impossible situations that defy reality and logic, such as believing one can fly without assistance.
Non-bizarre: Imagining possible situations that could occur in real life, such as believing one is being followed by the government.
Mood-congruent: Occurs when in a manic or depressive state, with delusions aligning with the prevailing mood, such as feelings of grandiosity during mania or worthlessness during depression.
Mood-incongruent: Happens without a particular mood's influence, with delusions unrelated to the individual’s emotional state.
Disorganized Speech
Signs of Disorganized Speech:
Word salad: Making illogical connections and statements that lack coherence, resulting in nonsensical communication.
Describing things in bizarre ways, with new or irrelevant words, such as using made-up words or terms that have no logical connection to the topic.
Saying sounds or words that do not make sense, creating unintelligible speech.
Speaking in tangents, veering off-topic and failing to return to the main point.
Derailment of thoughts, characterized by a sudden change in topic without any logical connection.
Loose associations: Characterized by a lack of connection between different ideas resulting in disorganized communication, making it difficult to follow the individual’s train of thought.
Assessment Cont.
Suicide Risk or harm toward others:
Ask client directly about suicidal or homicidal thoughts, intentions, and plans to assess the immediate risk.
Anger, hostility, or threats toward another person indicate potential for violence.
Specific threats, including detailed plans and intended victims, require immediate intervention.
Plans to harm someone, including methods and timing, necessitate urgent safety measures.
Duty to warn: Legal obligation to inform potential victims of credible threats.
Sensorium/intellectual processes:
Orientation: Awareness of person, place, time, and situation.
Memory: Ability to recall recent and past events.
Ability to concentrate: Focus and maintain attention.
Abstract thinking and intellectual abilities: Capacity for reasoning, problem-solving, and understanding abstract concepts.
Sensory-perceptual alterations:
Auditory hallucinations: Hearing voices or sounds that are not real.
Visual hallucinations: Seeing objects, people, or images that are not real.
Judgment and insight:
Ability to interpret environment: Understanding the context and implications of one’s surroundings.
Ability to understand the true nature of one’s situation: Recognizing the reality of one’s circumstances and potential problems.
Self-concept:
Personal worth and dignity: Perception of self-esteem and value as an individual.
Description of physical characteristics/body image: Evaluation of one’s physical appearance and satisfaction with their body.
Emotions the client frequently experiences: Identification of predominant feelings and emotional patterns.
Roles and relationships:
Current roles: Responsibilities and positions held in various aspects of life.
Ability to fulfill roles: Capacity to meet the demands and expectations of current roles.
Changes in roles: Transitions and adjustments in life roles.
Satisfaction with relationships: Level of contentment and fulfillment in interpersonal connections.
Online activity/social media: Assessment of online behaviors and potential impact on mental health.
Categories of family assessment: Evaluation of family dynamics, communication patterns, and support systems.
Physiological and self-care considerations:
Eating habits: Assessment of dietary patterns and nutritional intake.
Sleep patterns: Evaluation of sleep duration, quality, and disturbances.
Major or chronic health problems: Identification of physical health conditions that may impact mental health.
Use of drugs and/or alcohol: Assessment of substance use habits and potential dependence.
Noncompliance with prescribed medications: Evaluation of adherence to medication regimens and reasons for noncompliance.
Data Analysis
Overall assessment:
Not isolated bits of information but a comprehensive view of the client’s psychological and social well-being.
Patterns or themes in data → conclusions: Identifying recurring patterns and drawing meaningful conclusions about the client’s condition.
Clients' strengths: Recognizing and highlighting positive attributes and coping mechanisms.
Needs, problems: Identifying areas of concern and potential challenges the client faces.
Risks: Assessing potential dangers to the client or others.
Ongoing, dynamic process: Continuous monitoring and evaluation of the client’s progress and needs.
Psychological tests: Standardized assessments to evaluate cognitive and emotional functioning.
Psychiatric diagnoses: Formal identification of mental health disorders based on diagnostic criteria.
Mental status examination: Structured assessment of cognitive, emotional, and behavioral functioning.
Mental Status Examination
Client’s cognitive abilities:
Orientation to person, time, place, date, season, day of the week: Awareness of self and surroundings.
Interpretation of proverbs: Understanding of abstract concepts and metaphorical language.
Math calculations: Ability to perform basic arithmetic operations.
Memorization, short-term recall: Capacity to retain and retrieve information over brief periods.
Identification of common objects: Ability to recognize and name familiar items.
Ability to follow multistep commands: Comprehension and execution of complex instructions.
Ability to write or copy a simple drawing: Assessment of motor skills and visual-spatial abilities.
Psychological Tests
Intelligence tests:
Cognitive abilities: Evaluation of intellectual functioning and problem-solving skills.
Intellectual functioning: Assessment of overall cognitive capacity and potential limitations.
Personality tests:
Self-concept, impulse control, reality testing, major defenses: Assessment of personality traits, coping mechanisms, and psychological defenses.
Objective: Standardized questionnaires with fixed response options.
Projective: Open-ended tasks designed to reveal unconscious thoughts and feelings.
Two Basic Kinds of Tests
Objective tests:
Direct or self-report inventories: Questionnaires or surveys that directly ask about thoughts, feelings, and behaviors.
Subject must provide answers to a number of objective questions: Responding to standardized questions with predefined response options.
Questions assumed to be valid, normed on others: Relying on the established validity and reliability of the questions based on data from large comparison groups.
Use large groups of people as comparison group to validate: Comparing an individual’s responses to those of a normative sample to determine deviations from the average.
Projective tests: Present subject with ambiguous stimulus and ask for a response.
Subject should project a part of their personality into response: Encouraging the individual to reveal unconscious thoughts and feelings through their interpretation of the stimulus.
Assumed from Freudian defense mechanisms: Based on the Freudian theory that individuals project their unconscious desires and conflicts onto ambiguous stimuli.
Psychiatric Diagnoses
Diagnostic and Statistical Manual of Mental Disorders, Fifth Edition, Text Revision (DSM-5-TR).
Classifies mental disorders into categories based on specific criteria.
Describes each disorder, including its symptoms, prevalence, and course.
Provides diagnostic criteria for each disorder to ensure accurate and consistent diagnoses.
Self-Awareness Issues
Gather all information needed to form a comprehensive understanding of the client.
Judgments are not part of the assessment process; maintain objectivity and avoid biases.
Be open, clear, direct when asking about personal or uncomfortable topics to foster trust and encourage honesty.
Examine own beliefs to identify potential biases and preconceptions.
Gain self-awareness (growth-producing experience) to enhance empathy and understanding.
Do not allow personal beliefs to interfere with nurse–client relationship and assessment process; maintain professional boundaries.
Legal & Ethical Issues
Rights of Clients
Clients retain all civil rights, including the right to privacy, confidentiality, and informed consent.
Voluntary hospitalization:
Right to request discharge unless deemed a danger to self or others.
Only exception is involuntary commitment:
Danger to self or others: Legal criteria for involuntary hospitalization.
Committed until no longer a danger: Duration of involuntary commitment based on ongoing risk assessment.
Regulated by State laws: Specific legal provisions governing involuntary commitment vary by state.
Can be held for 48 to 72 hrs (Emergent Only): Initial period of detention for evaluation and stabilization.
Hearing may be needed to extend hold: Legal process for extending involuntary commitment beyond the initial period.
Committed clients:
Take medication and improve rapidly: Potential for symptom reduction and stabilization with treatment.
Symptomatic if meds are stopped: Risk of relapse and symptom recurrence upon medication discontinuation.
Providers can be held liable if released too soon: Legal responsibility for premature discharge that results in harm to the client or others.
Florida Specifics
B A 5 2: Involuntary examination, typically for up to 72 hours, to determine if an individual needs involuntary placement due to mental illness. This can be initiated by a judge, law enforcement, physician, or mental health professional.
B A 3 2: This is a continuation of the involuntary commitment, often after the initial 72-hour examination. It requires a court order and can be in place for a longer period.
BAR: Can sign consent for self, indicating the individual has the legal capacity to make their own decisions.
BAI: Must obtain consent from legal guardian, indicating the individual lacks the legal capacity to make their own decisions and requires a guardian to provide consent on their behalf.
Additional Legal Considerations
Health Insurance Portability and Accountability Act (HIPAA) of 1996:
Civil (fines) and criminal (prison sentences) penalties for violation of client privacy.
Penalties for violation of client privacy to protect sensitive health information.
Duty to warn third parties: Exception to client’s right to confidentiality when there is a credible threat to harm others.
Common Mental Health Challenges
Legal guardianship: Appointment of a legal guardian to make decisions for individuals deemed unable to care for themselves due to grave disability.
Incompetency:
Inability to provide self with food, clothing, shelter: Failure to meet basic needs for survival.
Inability to act in own best interests: Impaired decision-making ability and judgment.
Loss of right to enter into contracts: Legal restriction on entering into binding agreements.
Consent must be obtained from legal guardian: Requirement for guardian’s consent for medical treatment and other decisions.
Right to Least Restrictive Environment
Free of restraint or seclusion unless necessary to ensure safety.
May be necessary in situations where the client poses an imminent risk to themselves or others.
Restraint:
Restricts freedom or movement and can be:
Human: Physical holding by staff members.
Mechanical: Use of devices to limit movement.
Restraint/seclusion only for shortest time necessary and permitted only when client is imminently aggressive/dangerous.
Seclusion: Involuntary confinement in a room or area from which the client is not allowed to leave.
Restrictive Environment Assessment
Short-term use – MUST CHECK YOUR HOSPITAL POLICY for specific guidelines.
Face-to-face evaluation within 1 hour and then every 8 hours (every 4 hours for children) to monitor the client’s condition and assess the continued need for restraint or seclusion.
Physician’s order every 4 hours (every 2 hours for children) to authorize the use of restraint or seclusion.
Documented assessment by nurse every 1 to 2 hours to monitor the client’s physical and emotional well-being.
Close supervision of client, one-to-one monitoring for the first hour to ensure safety and provide support.
Debriefing session within 24 hours after release from seclusion or restraint to discuss the incident and provide feedback.
Insanity Defense
Insanity: Legal meaning but no medical definition.
Four versions:
M’Naghten Rule: Person did not know the act was wrong due to a mental illness.
Irresistible impulse: Person could not control conduct due to a mental illness.
Substantial capacity test: Person lacks substantial (but not total) capacity to know act was wrong due to a mental illness.
Durham: Person’s criminal conduct is excused if it was the product of a mental disease or defect.
Abolished in 4 States: Legal rejection of the insanity defense in certain jurisdictions.
Sets legal system free of responsibility: Shifts the burden of care and accountability away from the legal system.
People do NOT always receive MH treatment: Lack of guarantee for mental health care following acquittal based on insanity.
Nursing Responsibilities
Providing safe, competent, legal, and ethical care in accordance with professional and state guidelines.
Must Follow Professional and State guidelines, including:
American Nurses Association’s (ANA’s) Code of Ethics for Nurses with Interpretive Statements.
ANA’s Psychiatric–Mental Health Nursing: Scope and Standards of Practice.
Standards of care: Established benchmarks for quality nursing care.
State nurse practice acts: Legal regulations governing nursing practice within each state.
Federal agency regulations: Rules and guidelines set forth by federal agencies.
Agency policies and procedures: Internal protocols and standards within healthcare organizations.
Job descriptions: Defined roles and responsibilities for nursing positions.
Civil and criminal laws: Legal statutes that govern nursing conduct and potential liabilities.
Torts
Wrongful act resulting in injury, loss, or damage to another person.
Unintentional torts:
Negligence: Failure to exercise reasonable care, resulting in harm to another person.
Malpractice: Negligence by a professional, such as a nurse, in the performance of their duties.
Three elements to prove liability:
Willful, voluntary act: Intentional action that caused harm.
Intention to bring about consequences or injury: Deliberate intent to cause harm.
Act was a substantial factor in injury or consequences: Direct link between the action and the resulting harm.
Elements to prove malpractice:
Duty: Legal obligation to provide care.
Breach of duty: Failure to meet the standard of care.
Injury or damage: Harm suffered by the client.
Causation: Direct link between the breach of duty and the injury.
Intentional torts:
Assault: Threat of harm or unwanted contact.
Battery: Unconsented physical contact with another person.
False imprisonment: Unlawful restraint or confinement of a person against their will.
Ethical Issues
Utilitarianism: Decisions based on the greatest good for the greatest number of people involved.
Deontology: Decisions based on whether action is morally right or wrong, with no regard for consequences.
Deontologic Principles:
Autonomy: Right to self-determination and independence in decision-making.
Beneficence: Duty to benefit others or promote good.
Nonmaleficence: Requirement to do no harm.
Justice: Fairness and equitable distribution of resources and treatment.
Veracity: Honesty and truthfulness in all interactions.
Fidelity: Obligation to honor commitments and contracts.
Mandatory Outpatient Treatment
Continued participation in treatment as a condition of release from inpatient care.
AKA conditional release or outpatient commitment, requiring:
Taking meds as prescribed to manage symptoms and prevent relapse.
Follow up apts. with healthcare providers for ongoing monitoring and support.
Therapy and or Treatment groups to address underlying issues and promote recovery.
Clients given several opportunities for voluntary compliance before mandatory treatment is enforced.
Ethical Dilemmas in Mental Health
Ethical dilemma: Conflict of ethical principles with no one clear course of action.
Conflict of ethical principles: Clash between competing ethical values.
No one clear course of action: Uncertainty about the best ethical choice.
Involve client’s right to autonomy, utilitarianism: Tension between individual rights and the greater good.
Ethical Decision Making:
Gathering information to understand the situation fully.
Clarifying values to identify personal and professional ethics.
Identifying options to explore potential courses of action.
Identifying legal considerations and practical restraints to inform decision-making.
Building consensus for decision reached through collaboration and communication.
Reviewing and analyzing decision to evaluate outcomes and learn from experience.