3.3 Nursing Assessment and Clinical Tools

Physical Nursing Assessment

The nursing process starts with the assessment of the client. The physical assessment contributes to the psychosocial assessment. Clients in mental health treatment may be pregnant, using substances, or living with one or multiple chronic medical conditions, such as diabetes or hypertension. The psychiatric diagnosis may be caused or worsened by a physical factor, such as thyroid disorder or cardiac medications contributing to depression. During the physical assessment, the nurse begins to establish rapport with the client by introducing themselves and explaining the process of the assessment. It is essential the nurse be honest and allow for some flexibility in the assessment based on the client’s behavior, mood, stability, mental status, and general health. It is helpful to begin with creating the environment and ensuring the client’s privacy and safety. Ask the client what brought them into the health-care setting. Then, move into the details.

In a general hospital, psychiatric units may have an exam or treatment room equipped for medical procedures, such as suturing, wound care, women’s health, specimen collection, or full physical examinations. These procedures may be performed by professional consultants asked to visit the client. Clients from the hospital’s emergency department or from another facility may receive medical clearance as a prerequisite to psychiatry admission.

The physical data obtained by the PMH nurse is likely to be basic, and specifically indicated to clarify or add to psychosocial assessment findings. A personal search is policy in many treatment settings and involves a clothing check for items that are not allowed and observation of the client’s skin for rashes, wounds, and physical signs of abuse. Sometimes, clients are given different clothing to wear in the unit.

Vital signs are obtained and the client is asked about allergies and medications. The nurse may follow standing orders for routine or basic lab work and possible X-rays to assist the provider with diagnosis and to discover any issues that need further follow-up. The nurse should complete a neurological assessment initially because this baseline is necessary for the nurse to observe any decline or improvement in the client. The neuro assessment includes:

• Explaining to the client what the nurse will do and asking for permission to begin.
• Orienting to person, place, and time. The nurse will ask the client their name and date of birth, and verify with name badge/bracelet and chart information. This can include a picture of the client. This orientation often contains general knowledge questions: Who is the president of the United States? What season of the year is it?
• The nurse then must check the pupils for PERRLA (pupils equal, round, reactive to light and accommodation).
• Next, the nurse should check the client’s tongue to see if it is midline and does not deviate.
• The nurse all the while should be observing the behavior of the client to notice if they are cooperative with what the nurse is asking them to do.
• The nurse will test the strength of the client’s grip and their ability to push against the nurse’s hands.
• The nurse will assess the client’s gait and how prone to falling the client may be. Asking the client to walk on their heels or stand on tiptoe can help the nurse determine the client’s sense of balance.

Once this is completed, the nurse should document the findings.

The physical assessment could also include auscultation of the lung and heart sounds, and this must be done in a trauma-informed manner, which is discussed in Chapter 2 Fundamentals of Theories and Therapies. The nurse explains the procedure to the client and is mindful of the effect of touch. Nursing judgment determines how this part of the assessment will be done.

It is vital to establish if the client is thinking about suicide or harming others. This is a crucial safety aspect. If the client reveals this, the nurse needs to gain more insight into how, when, and who they are thinking of hurting.

Psychosocial Assessment

A psychosocial assessment is an evaluation of a client’s mental health in relation to their social well-being. The psychosocial assessment looks at self-perception and the client’s ability to function in the community. The objective of the psychosocial assessment is to establish a baseline for the client and understand the client to provide the best care possible for their mental health. Generally, the environment for the psychosocial assessment should be calm, clean, private, and safe for the client and the nurse. The nurse can offer the client a chair. Nurses should help the client to feel comfortable by using a nonjudgmental tone and exhibiting open posture. It is important for the nurse to explain what will happen to help the client feel at ease, know what to expect, and alleviate the client’s fear and anxiety.

The psychosocial exam can begin by asking clients about their employment and continue by asking them to describe their current living situation. While asking these questions, the nurse should observe the client’s facial expressions, bodily movements, eye contact, posture, tone of voice, and different noises or tics they may have. Is the client jittery, looking around the room, lacking focus on the questions? Is the client mumbling, pointing to items that are not present, or asking if you see something (a hallucination) that is not present? The nurse must be vigilant about noticing the client’s behavior and ask questions that help the client articulate what they are experiencing. Questioning the client about their current and most recent mood is helpful. Inquiring about how the client copes with stress can offer the nurse insight into how the client is coping now and how they have historically coped with stressful events.

The aspects of the psychosocial assessment are:

• home environment
• education/employment
• activities outside of work/hobbies
• drug/tobacco/alcohol use
• sexuality/gender
• suicide risk
• violence risk

Home environment means determining how safe and secure the home is and how the client relates to those in the home: parents, children, spouse, significant other, roommate. How do they interact with them, are there frequent arguments, how are arguments resolved, and how does the client cope with the living arrangement?

Education/employment establishes the level of education the client has at the time of the assessment and what the client does for employment. Does the client have a plan or desire to change their job or education level and, if so, how and where are they on this change?

Questions about activities outside the workplace/hobbies determine what the client enjoys doing with their time outside of working. Does the client play sports, create art, enjoy woodworking or reading? What does the client aspire to do for leisure?

Drug/alcohol use is important to assess because clients may use substances to self-medicate or cope with stress and anxiety. Ask the client, without judgment, if there is use of illegal or illicit drugs. It is vital to know when and how much the client has taken and regularly takes when it comes to illicit drugs or alcohol. Withdrawal can affect a client’s health and medical and mental stability. The nurse should also ask about over-the-counter medications, herbal remedies, complementary medications, and prescription pain medications. There may be misuse and/or contraindications between these and drugs to be prescribed.

Tobacco use/vaping is also something to investigate. Clients who use tobacco are often limited in their use when admitted to hospital care units. Some facilities are completely nonsmoking. The assessment is a good time to explain this and to determine if the client is a candidate for nicotine replacement therapy or smoking cessation support. This is individualized and should be considered when discussing the plan of care for the client.

Sexuality also requires discussion. Sexuality covers partner preferences, whether or not the client is sexually active, and if they understand how to protect themselves from sexually transmitted infections, unintended pregnancy, and interpersonal violence. Further conversations on these topics can be part of the client’s plan of care.

Ask the client about their gender identity and preferred pronouns, and strictly abide by their voiced preferences. How the client identifies should be clear in the documentation, so the entire staff can be respectful.

Tools Available for Psychosocial Assessment

There are many psychosocial assessment and mental health screening tools to use (Figure 3.5). The facility policy will dictate which tool to use. Here is a list of the most common assessments:

• Mini Mental Status Exam
• Mental Status Exam
• Brief Psychiatric Rating Scale (BPRS)
• World Health Organization Disability Assessment Schedule 2 for psychiatric clinicians (WHODAS 2.0)
• McMaster Family Assessment
• Addiction Severity Index (ASI)
• Recovery Attitude and Treatment Evaluator (RAATE)
• Brief Drug Abuse Screen Test (B-DAST)

Figure 3.5 A general psychosocial assessment covers several areas of a client’s life to determine the client’s mental health and social well-being. (attribution: Copyright Rice University, OpenStax, under CC BY 4.0 license)

Clinical Judgment Measurement Model

Clinical judgment is key to working with clients with psychiatric illness. When the client is in crisis, the nurse must recognize the signs and symptoms and determine what action to take to keep the client and others safe. The Clinical Judgment Measurement Model (CJMM) was developed by the National Council of State Boards of Nursing to assist graduates to answer client care questions on the nurse licensure exam. The CJMM provides a nursing framework to decipher client problems. The nurse must recognize cues, analyze them, decide if the cues are important enough to act on immediately or if can they wait, identify and prioritize problems, then generate and implement a plan of action/intervention/solution.

There are many scenarios where a nurse practicing in psychiatric care should use this model. For example, suppose a client is admitted and is actively suicidal. The nurse recognizes the cues from the client, prioritizes the need for safety, then formulates the solutions to help the client. Another example is when the client is actively psychotic and is aggressive and hostile toward the other clients in the unit. The nurse again recognizes the cues of unpredictable behavior, lack of impulse control, and delusions. After recognizing the cues, the nurse will analyze the cues and determine actions, such as changing the client’s room, administering certain medications immediately and others later if they can wait, and assigning a staff member to monitor the client’s actions to keep everyone safe. The Clinical Judgment Measurement Model offers a guiding framework to assist the nurse to answer NCLEX questions about client care.