The assessment process in

mental health nursing.

Author(s): Joana Fornés Vives.
Introduction.

Valuation is the process of and obtain information about the person as a

whole, not only about the needs or dysfunctions that need to be treated, but
also about physical, intellectual, social, cultural and spiritual aspects.
According to Stuart and Sundeen (1995b), the more complete the picture,
the more likely the treatment will be effective.

In the nursing care process, assessment is the first step in a sequence that
consists of collecting data that clarify the user's situation and problems.
Information and data relating to the user are obtained from all possible
sources. Medical records are reviewed, a nursing history is taken,
observations are made, and ideas are exchanged with family members or
friends. An image of the user, client or patient thus begins to emerge.

The next step is to classify the data into related areas, and identify any
problems or concerns. Each problem is examined and a nursing diagnosis is
established. Subsequently, we move on to the planning phase
(establishment of objectives or expected results and interventions to be
carried out), where the nursing staff determines what behaviors will indicate
the solution to the diagnosed problems. At this point, we must remember
that many nursing actions are culturally significant for the user, both for
their understanding and for subsequent therapeutic action or follow-up.

Below is a brief reflection on the main aspects that constitute the mental
health assessment process: types of assessment, types of data and way of
obtaining them, and main areas of personal assessment; regardless of the
theoretical reference model used.

Types of assessment in mental health nursing

The type of assessment used in a given situation is determined by the

nature of the client's history, current problems, and other individual needs.
As Johnson (2000a) points out, it is important to use a standardized format
for recording data, while maintaining some flexibility.

Various purposes, objectives, and methods differentiate assessments

(Gordon, 1994, 1996; Johnson, 2000a). In this sense, Johnson (2000a)
speaks of a broad assessment, a focused assessment and a selective
assessment (use of a specific instrument or protocol to detect a specific
problem) and Gordon proposes four types of assessment: initial assessment,
assessment of a problem focused, assessment after a long period of time
and urgent assessment.

According to Johnson and Gordon, assessment is always necessary to

initiate a therapeutic practice. However, the type of situation that arises,
the associated problems and possible consequences, as well as the
proposed objectives, will constitute a frame of reference and a specific type
of record.

Collecting the contributions of both authors, we could consider different

types of assessment:

Broad rating

It is generally the initial assessment, except in emergency cases. The

purpose is to assess the client's health status, identifying any problem or
dysfunction that may occur and subsequently establish a therapeutic plan,
using and promoting interpersonal relationships.

It includes a complete psychosocial and cultural nursing history, physical

examination, and general information about the client based on criteria by
which changes will be evaluated.

Many times the initial assessment cannot judge a health problem from the
beginning, without verifiable data. In this phase you must be open to the
information that you want to give or that can be obtained from the client, to
hypothesize health problems.

It is important that the information is recorded in a standardized format,

with common scientific terminology so that it can be understood by all
professionals on the team and used later.
Focused assessment (or of a focused problem)

The purpose is to assess the presence or absence of particular problems or

diagnoses, anticipate new problems, and alert about forgotten or
undiscovered problems and erroneous problems.

Focused assessment includes information relevant to a given problem, with

systematic collection and analysis of objective and subjective data. A
thorough description of the factors that contribute to the problem must be
made and prioritized for intervention. The analysis involves exploring the
nature and intensity of the problem, the time and context in which it occurs,
the associated problems, and the meaning that the problem has for the
person.

The structure for collecting information differs somewhat from the initial
assessment. In this case, the information must be structured using
parameters of the problem, generally agreed upon as nursing diagnoses or
health problems with nursing intervention.

Continued appraisal (or revaluation after a period of time)

The purpose is to evaluate changes in the client's detected problems and

functional patterns, as well as the emergence of new problems or
dysfunctional patterns.

In this type of assessment, the time elapsed since the previous assessment
can be considerable (for example weeks or months in Primary Care). The
client's health patterns and status may have changed. Natural development,
health management practices, or elapsed time may have had their effects.
Likewise, it is possible that non-productive problems have appeared due to
health practices or situational factors.

Urgency assessment

In these cases the purpose focuses on:

1. Identify the situation as urgent or non-urgent

2. Quickly determine the nature of the emergency
3. Intervene quickly
Subsequently, the assessment could be focused as a broad assessment
and/or a focused problem.

Data collection in mental health

Assessment data is derived from data collection, interview, and behavioral

observation. In mental health, whenever possible, data should be validated
(especially those obtained directly from the patient's verbal expression).

The main methods of collecting information in nursing are the same as

those used in science: the interview, observation techniques and rating
scales or inventories. Each method overlaps the other. For example, during
the interview, the nurse also applies observation techniques and
interviewing skills.

The interview, usually a face-to-face meeting for the purpose of exchanging

information (Keltner et al., 1995), also serves as a starting point to establish
the therapeutic relationship. Interviews can be formal and highly structured
or informal and casual. The information obtained from formal interviews is
usually recorded in a standardized way. Informal interviews often occur by
chance, but are a good opportunity to learn more about the patient and their
family.

Observation is defined as the process of looking at a purpose (Fortinash and

Holoday-Worret, 1995), it is also called inspection, which in the case of
mental health means the examination of the body in order to detect aspects
or characteristics related to possible dysfunctions. To achieve this goal, the
nursing professional uses all the senses, especially sight, hearing and
touch.

Observation is an excellent method for obtaining mental health information,

but only when the nurse remains impartial and does not make value
judgments. When applying this technique, one must be careful and objective
and remember that personal prejudices or attitudes can alter perceptions
and affect the objectivity of observations.

Rating scales and inventories are instruments designed to highlight certain

types of specific information, for example, IQ, personality characteristics,
specific abilities, etc. The results are compared with standard
measurements. These types of instruments can be very useful in focusing on
certain aspects of the patient's disorders, but as with other instruments or
data collection techniques, they must be applied without judgment.

Type of data

When carrying out a thorough assessment of the person with mental health
problems, it is important to include objective data and subjective data.
Objective data refers to information that can be measured and shared. This
type of information is obtained through the senses of sight, smell, touch and
hearing, and can be shared with other people. When working with mental
health patients, nurses obtain this data through physical examination, daily
nursing assessment, results of diagnostic tests, and repeated observations
of the patient's behavior.

Subjective data is related to the patient's perceptions. They include

abstract and difficult-to-measure information from the patient's perspective
on a situation or series of events, feelings, ideas about oneself, and
personal health status. The data is recorded in the patient's own words.

All feelings, emotions and mental states are subjective and difficult to
measure, therefore, it is very important to leave a written record of
subjective information in the most descriptive and precise way possible.
Verbatim quotes are used to capture the importance of the client's problem
or situation that led them to seek help. Using the same words that the
patient said is helpful for understanding. It is also important to accept
whatever is said and then note any inconsistencies or inconsistencies,
which can be explored later. Interpretative statements (judgments) should
not be included.

Main areas of assessment in people with mental health

problems.

In any assessment process, it must be taken into account that physical

functions, although important, are only a small part of the person, and that
they are closely linked to other cultural, sociological and spiritual aspects.
In mental health nursing practice, the assessment process should include
all these aspects, and place special emphasis on those areas related to
cognitive and emotional aspects. Regardless of the theoretical or care
model used, the main areas of assessment should include the following
aspects:

General description

It includes everything that can be observed at first glance in the patient,

such as physical characteristics, hygiene, attire, facial expression, way of
speaking, motor activity, reactions or behaviors, attitude towards the
interview (collaborative or not), etc. This description would include the
following parameters:

1. Physical characteristics: Note anything unusual that is noticed through

observation. Ahem. Skin color, presence of bruises, scratches, etc. Describe
the person's complexion.

2. Degree of body hygiene and attire: Body odor, appearance of skin and
clothing (clean and neat or unkempt), way of dressing (use of cosmetics,
colors of clothing, use of ornaments or strange clothing), especially
observing whether the Attire adjusts to age, sex and situation.

3. Facial expression: Use or avoidance of eye contact, size of the pupils,

whether the facial expression corresponds to emotions and actions,
presence of tics or grimaces, etc.

4. Mode of speaking: Speed, volume and abnormal characteristics.

5. Motor activity: Gestures and postures. Unusual movements, tics, tremors,

agitation, lethargy.

6. Reactions or behaviors: Behavior during the interaction (cooperative,

hostile), observe if the verbal message is consistent with the behavior.

Physical evaluation

It involves detecting any physical problem that could pose a threat to the
person's well-being. Many behavioral disorders are often linked to a physical
cause; for example, low blood sugar levels, exposure to toxic substances, or
acute pain can lead to confusion, irritability, or perceptual disturbances.
Assessment of risk factors

The purpose is to detect factors that may pose an immediate potential

threat to the patient (Stuart and Sundeen, 1995a). Attention is focused on
the following aspects:
- Probability of suicide or self-harm
- Potential for aggression or violence
- Probability of withdrawal syndrome
- Probability of allergic or adverse reactions to drugs
- Probability of seizures
- Probability of falls or accidents
- Probability of escape

Sociocultural evaluation

The sociocultural evaluation focuses on cultural, social and spiritual

aspects of the person that may interfere with achieving a healthy pattern of
mental health. Morrison (1999) proposes six areas of evaluation in this
section, referring to: age, race (culture), education, income and beliefs.

Emotional state

In this case, the patient's mood and affect must be considered. Mood refers
to the person's set of feelings; it is a subjective factor that can only be
explained by the person who feels it.

Affect is the emotional display that a person makes of their state of mind.
Its observation is very important in mental health nursing, especially in
patients who are not very verbally communicative, the nurse can deduce (an
aspect that must later be confirmed) their state of mind and guide a
therapeutic action. It is equally important to observe whether the displays
of affect correspond to the motor activity, since in some patients it is a fact
that clarifies the clinical diagnosis.

In communication between health professionals, affect can be described:

a) Regarding the tone:

- Pleasant: It is characterized by its pleasant tone
- Unpleasant: Implies an unpleasant tone for the patient
b) Regarding adaptation to the context:
- Appropriate. The emotional state coincides with the real situation.
- Inappropriate. Does not match the person's immediate circumstances
In this sense it can be:
1. Labile. It denotes rapid changes that cannot be understood in the
context of the situation.
2. High. It refers to a feeling of euphoria or excitement
3. Depressed. Indicates feelings of dejection and sadness
4. Hyperreactive. Appropriate to the situation but disproportionate

Sensory, perception and cognition

They are the basic mental functions that govern much of human behavior.
Its exploration is important to identify mental health dysfunctions and their
possible causes.

1. Sensorium.

The sensorium is the part of consciousness that perceives, classifies and

integrates (combines) information. It therefore includes information about
consciousness, attention-concentration, memory and orientation.

* Awareness. It can be determined by observing the amount of stimuli

necessary to mobilize the patient. The main alterations are usually
classified as: hypervigilance, lethargy, obtundation, stupor, and coma.

* Attention and concentration. It focuses on the person's ability to pay

attention during the conversation. The factors that determine care and that
the nurse must assess may come from the outside world or from the
patient's internal field.

* Memory. It is the ability to remember past events, experiences and

perceptions. For evaluation purposes it is divided into three categories:
Immediate, recent and remote memory.

* Orientation. Temporospatial orientation is understood as

the person's ability not only to recognize themselves, but also to
consciously and mentally locate themselves in a specific place and time.
Therefore, it implies knowing who you are, where you are, and what date,
place and time you are.

For good temporal-spatial orientation to exist, the following psychic devices

must function well: attention, understanding, rational thinking, perception
and memory.

2. Perception.

The phenomenon of perception refers to the acquisition of knowledge of the

sensory data of our world. Perception, like consciousness and attention, is
closely related to memory.

A person's perceptions are usually related to one's own reference

framework and from a psychopathological point of view, the alterations do
not refer so much to sensory deficiencies as to cognitive alterations.

People with mental health problems may have difficulty perceiving the same
reality as the rest of society. For example, the patient may hear voices or
see things that other people do not perceive.

The main perceptual alterations are classified as:

* Hallucinations. Perception without an object and with conviction of the

reality of the phenomenon by the subject who suffers it.

* Pseudohallucinations. Objectless perception that responds to imagined

experiences that frequently appear in the internal space of the subject.

* Hallucinosis. Perceptions without an object but correctly criticized by the

subject who experiences the phenomenon as pathological.

* Illusion. Falsification or distortion of a real perception. There is the

effective presence of sensory data with distortion of what is perceived.

3. Thought and language.

In the mental status examination, this section focuses on the content and
the patient's course or process of thought. The problems in the content have
to do with the "what" thinks (the idea) and have their maximum pathological
expression in delirium, which can have different themes. The most common
themes are:
- Depressive (hypochondriacal delusions of ruin and guilt)
- Persecution (physical persecution and psychic persecution)
- Mysticism and possession
- Megalomaniac or greatness
- Jealousy
- Erotic

The problems in the process have to do with "how" you think (how you
connect and organize information). They refer to the alterations manifested
in the course of ideas or in the spontaneity of the verbal flow, and not in its
elaboration. The main disorders are: inhibition of thought, acceleration of
thought and flight of ideas.

Other times, no alteration is detected in the construction of the idea but in

the language used to communicate. These alterations are known as
morphological, verbal course and rhythm, syntactic and semantic disorders.

Bibliographic references

(Fortinash, K.M.; Holoday-Worret, P.A. (1995). Psychiatric nursing care plans.

St. Louis: Mosby.

Gordon, M. (1994). Nursing Diagnoses: Process and application. St Louis,

Missouri: Mosby-Year Book Inc. Madrid: Mosby, 1996.

Gordon, M. (1996). Nursing diagnosis. Process and application. Madrid:

Mosby

Johnson, B.S. (2000a). Mental health and psychiatric nursing. Volume I.

Madrid: McGraw-Hill-Interamericana.

Keltner, N.L.; Schwecke, L.H.; Bostrom, C.E. (1995). Psychiatric nursing. St.
Louis: Mosby.
 Morrison, M. (1999). Fundamentals of mental health nursing. Madrid:
Hancourt Brace – Mosby.

Stuart, G.W.; Sundeen, S.J. (1995a). Principles and practice of psychiatric

nursing. St. Louis: Mosby.

Stuart, G.W.; Sundeen, S.J. (1995b). Pocket guide to psychiatric nursing. St

Louis: Mosby.

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21 comments
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1. 01

Enrique Ilundain April 25, 2001 19:07

Fornés article. Hello, Joana, I hope you still remember me after the CVP. I
am writing to you from the most complete ignorance in this regard to ask
you about the sociocultural assessment according to Morrison. Do you really
equate race with culture, or is it an ellipsis applied by you? If the first is
true, I think I should review your book, to catch up in the first place, and
secondly to verify the culturalist nonsense that North American authors may
be invading us with. Let the people of the Transcultural Nursing Society do
it, it still happens, because they are a very closed circle and we barely get
any influence from them; but I understand that Morrison's book is having a
great diffusion among us... If you can, explain something more to me. Nice
to greet you again, a hug,
Enrique

2. 02
 Esther May 18, 2001 15:50

Important!. Hello! I am a nursing student and I am doing a project on

phobias. I would like to know how this disorder is treated at the nursing
level, what the nursing care plans are!!!
We are having a hard time finding cases of geneticists with serious phobias.
But I already said that what interests me is the attention that the nurse
gives to a patient with phobic disorders.
Thanks for your attention.

3. 03

Ester Muñoz May 30, 2001 1:29 p.m.

RE: IMPORTANT! I am also a nursing student and I am in my last year. I just

read your message and I think that a care plan for this pathology will be
aimed at calming the anxiety that the phobia causes in these types of
patients, whatever the type. Likewise, depending on the phobia, you may
have some alterations, whether because, for example, you have a phobia of
water, you may have an alteration of the skin's integrity...
If you tell me what type of phobia it is, I will try to help you to the best of
my ability. I hope I can help you soon and good luck.

4. 04

Viviana Ampuero June 6, 2001 2:47

I liked your page. This information is required for training in patient

assessment.
I hope you answer me.
Sincerely, Viviana

5. 05

Oscar July 25, 2001 6:26

 RE: IMPORTANT! Exactly what you mentioned, phobia of water.
Thank you

6. 06

Rosa Del Cid August 14, 2001 23:54

terminology. I am a social worker in California who works with Spanish-

speaking people. My colleagues and I want to know if there is somewhere
on the Internet that can teach us how to translate English mental health
terminology into Spanish. Your help would be very appreciated.

Thank you,
Rosa Del Cid

Note: This article did help me a little. Thank you.

7. 07

CARLOS MORA ARTAVIA September 19, 2001 17:40

psychological behavior in expression. MAYBE MY FRIENDS WOULD LIKE TO

KNOW ABOUT THE SCOPE OF EXPRESSION IN THE BEHAVIOR OF
INDIVIDUALS, FOR EXAMPLE EXPRESSION AS A PROFILE OR PERSONALITY
OF THE INDIVIDUAL... I AM TAKING A COURSE AT THE UNIVERSITY OF
COSTA RICA REGARDING THE TOPIC. BELIEVE ME I AM VERY GRATEFUL.
IN ADDITION, I DIRECT ACTIVITIES WITH YOUTH GROUPS ON CONDUCT
AND BEHAVIOR IN INTERACTIVE ANIMATION WITH A SMALL MOBILE DISCO
WE ARE A SMALL COMMERCIAL ANIMATION COMPANY...THANK YOU VERY
MUCH
I ALSO WORK IN THE MINISTRY OF ENVIRONMENT AND ENERGY MINAE,
ON WEEKENDS I DEDICATE MYSELF TO THESE ACTIVITIES. GOD BLESS
YOU
AND THANK YOU

8. 08
 rafel contreras October 4, 2001 19:52

I have problems, and I need help. I think I'm schizophrenic

9. 09

Carmen Bárcena October 25, 2001 19:19

RE: I liked your page. I loved your approach but I still don't see what model
we can use in Mental Health, I know that flexibility is important and that
perhaps several fit, but from your perspective which is the most appropriate
and what are the reasons for it?
Thank you very much for your dedication.
Warm greetings

10. 10

otoniel November 1, 2001 7:45

Delighted with your page. When I discovered your site, I was interested in
the nursing facility, since I am a 5th year student of a degree in nursing, and
I would like to know if there is a degree in the specialty in your country, if
not, what name is it similar to? what it deals with.
I think the article is very complete, and should be adjusted to each country
and the conditions that favor or predispose the appearance of psychiatric
pathologies.
I am Cuban, and in my country due to economic deficiencies there is an
increase in these pathologies, and stress.
I like to send you my opinion, but I like more that the information flows.
Thank you

11. 11

eva November 1, 2001 23:40

 I'm interested. I love the article. I would like to keep in touch. I am a nurse
with a specialty in psychiatry, but I haven't retrained in years. I think I'm not
up to date. Greetings.

12. 12

vivian rios ramirez November 18, 2001 3:59

care help. I need to get a care plan for a patient with bipolar disorder. It is a
project to submit from the university where I study in ermeria and I need
help

sincerely
vivian rios ramires

13. 13

Joana Fornés November 21, 2001 15:41

RE: I'm interested. Thanks for your opinion. You see that the contact is
active. All the best.

14. 14

Joana Fornés November 21, 2001 15:43

RE: Delighted with your page. otoniel wrote:

>
> When I discovered your site I became interested in the place
> nursing, since I am a 5th year undergraduate student
> in nursing, and I would like to know if the
> degree of the specialty, if it does not exist, which
> name resembles what it deals with.
> I think the article is very complete, and should be adjusted to
> each country and the conditions that favor or predispose
 > appearance of psychiatric pathologies.
> I am Cuban, and in my country due to economic deficiencies there are
> increase in these pathologies, and stress.
> I like to send you my opinion, but I like more that it flows
> the information.
> Thank you

15. 15

Joana Fornés November 21, 2001 15:48

RE: Delighted with your page. I think an error has occurred with the
response to the previous message.
Thanks for your opinion. Regarding your initial question, I inform you that in
Spain some private universities grant the degree of Bachelor of Nursing,
although said degree is not yet approved by the Ministry of Education.
The official title is a Diploma in Nursing, subsequently, you can study the
specialty of Mental Health Nursing, for one year (residency type and paid).
All the best.

16. 16

Jaime December 6, 2001 22:31

RE: I have problems, and I need help. I am a nursing student and I am in the
7th semester and I would like to know the format of a psychiatric evaluation

THANKING YOU FOR YOUR PROMPT RESPONSE, I SEND YOU MY MOST

CORDIAL GREETINGS

17. 17

Maria de Lurdes Braun January 11, 2002 2:51

 psychiatric nursing project. Hello, I am a psychiatrist from Brazil, I am
running a psychiatric ward for 12 patients with various psychiatric
pathologies, in a general hospital in the city of Foz do Iguacu – Parana –
Brazil.
If possible, I would like to know better about your project by e-mail.
Thank you,
Maria de Lurdes Braun

18. 18

Joana Fornés January 29, 2002 18:52

RE: psychiatric nursing project. I will be happy to exchange information with

you on this matter. You can contact me at the attached email. Thanks and
kind regards.

19. 19

pppiastor March 18, 2002 4:50

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Come on, girls, stop touching the guys...

Yours is from so much crushing it, you sudaca son of a bitch...

JUAS JUAS

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20. 20

lusia March 18, 2002 4:53

I answer you, I can help. beras jaime I love lusia I'm from Colombia and I'm
34 years old
I have been involved in prostitution since I was 12 and I am an expert in
 blowjobs and mouthfuls.
If you want, come here so I can fix you for a while, okay?
bye

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21. 21

Luis March 18, 2002 4:55

I have a problem. I am sexually attracted to my grandmother, what do I do?

I also get pricked