Therapeutic Process

NURSING PROCESS

PSYCHOSOCIAL ASSESSMENT

  • Purpose:

    • Provides a comprehensive picture of the client’s emotional state, mental capacity, and behavioral function.

    • Forms the basis for developing the plan of care.

    • Serves as a clinical baseline to evaluate the effectiveness of treatment and measure the client’s progress.

FACTORS INFLUENCING ASSESSMENT

  • Key Influencers:

    • Client participation and feedback during the assessment process.

    • The clinical presentation of the client.

    • Previous experiences or misconceptions the client has regarding healthcare.

    • The client’s ability to understand the information presented.

    • The nurse’s attitude and approach when interacting with the client.

PROJECTION VS TRANSFERENCE

  • Projection:

    • Involves attributing one's own feelings or behaviors onto another person.

    • Example: Disliking a boss and convincing oneself that the boss shows dislike back.

  • Transference:

    • Involves redirecting feelings or desires for one person onto another unrelated person.

    • Example: Observing traits of one's father in a new boss and attributing feelings towards that boss based on past experiences.

TRANSFERENCE ISSUES

  • Transference:

    • A phenomenon where a person in therapy redirects feelings from others onto the nurse.

  • Countertransference:

    • Occurs when a nurse projects their own emotions onto the person in therapy.

THE INTERVIEW

  • Environment:

    • Should be comfortable, private, and safe for the client.

    • Quiet settings with minimal distractions are ideal.

    • Input from family, friends, and other healthcare providers can provide valuable insights about the client's perceptions.

THE INTERVIEW: QUESTIONS

  • Question Types:

    • Use open-ended questions to initiate the assessment process.

    • Use focused questions if the client struggles to organize their thoughts or respond to open-ended inquiries.

ASSESSMENT CONTENT

  • History of Present Illness:

    • Evaluate the timeline of the illness, age of onset, and symptomology.

    • Review any previous treatment, suicide attempts, or hospitalizations.

    • Consider cultural and spiritual beliefs impacting the client's situation.

ASSESSMENT CONTENT: APPEARANCE AND BEHAVIOR

  • Key Observations:

    • Evaluate the client's hygiene and grooming.

    • Note appropriate dress, posture, and eye contact.

    • Observe for any unusual movements or mannerisms in behavior.

    • Assess speech patterns.

ASSESSMENT CONTENT: MOOD AND AFFECT

  • Common Terms:

    • Flat (no emotion) vs. Blunted (mild expression) vs. Inappropriate affect.

    • Constricted affect (mild reduction) and variations like Angry, Euthymic.

ASSESSMENT CONTENT: THOUGHT PROCESS AND CONTENT

  • Assessment Areas:

    • Evaluate the client's thought processes (how they think) vs. content (what they say).

    • Directly assess for suicidal ideation or harm toward others, recognizing anger, threats, or specific plans.

C-SSRS: C-SSRS SUICIDE RISK SCREENING TOOL

  • Key Questions:

    1. Have you wished you were dead or not wanted to wake up?

    2. Have you had thoughts of killing yourself?

    3. Have you thought about how you might kill yourself?

    4. Have you had these thoughts with intent to act on them?

    5. Have you worked out details for how to kill yourself?

    6. Have you ever done anything to end your life? (lifetime or within the past 3 months)

ASSESSMENT CONTENT: SENSORIUM PROCESSES

  • Key Areas to Assess:

    • Auditory and visual hallucinations.

    • Client’s judgment and insight regarding their environment and personal situation.

ASSESSMENT CONTENT: SELF-CONCEPT AND RELATIONAL DYNAMICS

  • Self-Concept:

    • Understanding personal worth, dignity, and emotions frequently experienced by the client.

  • Roles and Relationships:

    • Current roles, ability to fulfill those roles, changes, and satisfaction with relationships.

ASSESSMENT CONTENT: PHYSIOLOGICAL AND SELF-CARE CONSIDERATIONS

  • Key Considerations:

    • Eating habits and sleep patterns.

    • Presence of major or chronic health issues.

    • Use of drugs or alcohol, including medication noncompliance.

MEDICATIONS

  • Medication History:

    • Create a comprehensive timeline detailing administration, dosage, frequency, indications, side effects, and effectiveness of medications used.

    • Identify which medications the client found most effective and how they remember to take them.

MENTAL STATUS EXAMINATION

  • Assessment Areas:

    • Evaluate cognitive abilities regarding orientation to person, time, place, season.

    • Assess basic math skills or memorization, additionally examining short-term recall.

    • Identify common objects and follow multistep commands.

    • Client’s ability to write or replicate simple drawings.

DATA ANALYSIS

  • Overall Assessment:

    • Focus on identifying patterns or themes within the collected data.

    • Utilize findings to draw conclusions about the client's strengths and needs, applying North American Nursing Diagnosis (NANDA) principles.

    • Common NANDA diagnoses may include Risk for Suicide, Ineffective Coping, Imbalanced Nutrition, Chronic Low Self Esteem, and Hopelessness.

DATA ANALYSIS: PSYCHIATRIC DIAGNOSES

  • Utilization of DSM-V:

    • Diagnostic and Statistical Manual of Mental Disorders (DSM-V) provides criteria for diagnosing various mental disorders.