Transcript Process Assessment PPT

The Assessment Process
Chapter 11
Assessment as a Process
Deliberate and systematic collection and
interpretation of biopsychosocial
information or data to determine current and
past health, functional status and human
responses to mental health problems, both
actual and potential
Assessment
• Initial Assessment
– Comprehensive – all data
– Screening – Recognize symptoms, risk factors
or emotional difficulties.
• Ongoing Assessment
– Monitor the progress and outcomes of the
interventions.
– Focused
Techniques of Data Collection
• Patient observations
• Interviews - patient and family (Text Box
11.2)
• Physical examination
• Records and diagnostic reports
• Collaboration with colleagues
Biopsychosocial Assessment
Text Box 11.3: Biologic Domain
• Present and Past Health Status
• Physical Examination
– Body Systems Review
– Neurologic Status
– Laboratory Results (Table 11.1)
• CBC
• Electrolytes
– Na+, K+
• Renal Function Tests
– BUN, Creatinine
• Serum enzymes
– Amylase, SGOT, CPK
• Thyroid Function
– T3, T4, TSH
Assessment: Biologic Domain
• Physical Functions
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Elimination
Activity and exercise
Sleep
Appetite and nutrition
Hydration
Sexuality
Self-care
• Pharmacologic
– Current and past medications
– Over-the-counter, vitamins, herbal supplements
Assessment: Psychological Domain
• Responses to mental health problems or consequences
• Mental status examination
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General observation, appearance, psychomotor activity, attitude
Orientation
Mood, affect, emotions
Speech
Thought processes
Cognition and intellectual performance
Attention and concentration
Abstract reasoning and comprehension
Memory: recall, short-term, long-term (remote)
Judgment and insight
MMSE
(Text Box 11.5)
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Orientation
Registration
Attention and Calculation
Recall
Language
Assessment: Psychological Domain
• Behavior
• Self-concept
– Body image
– Self-esteem
– Personal identity
• Stress and Coping Patterns
• Risk Assessment
– Suicidal ideation
– Assaultive or homicidal ideation
Suicide Assessment
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Have you ever tried to harm or kill yourself?
Do you have thoughts of suicide at this time?
If yes, do you have a plan?
If yes, can you tell me the details?
Do you have the means?
Have you made preparations? Giving things
away, etc.
• Has a significant episode made you feel this way?
Assaultive or Homicidal Assessment
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Do you intend to harm someone?
If yes, who?
Do you have a plan?
If yes, what are the details of the plan?
Do you have the means to carry out the plan?
Where is the weapon?
Social Assessment
• Functional Status
• Social Systems
– Family assessment
– Cultural assessment
– Community support and resources
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Spiritual Assessment
Occupational Status
Economic Status
Legal Status
Quality of Life