Introduction to Mental Health Nursing Assessment

Year 2 Semester A 2008

Willie McDonald

Aims

What is it and why is it important

Skills involved in Mental Health Nursing Assessment

Approaches, Methods and Process

Assessment tools

Assessment – What is it?

“Estimating the character of something or someone” Barker (2004)

At the heart of assessment: the collection of information with the intention of making a judgement

Each time we set out to find out something new, we embark on an assessment

Usually undertaken with a view to some action in the future

Assessment – Why is it Important?

“You can’t really help people unless you are first able to assess their problem”

Barker (1985)

“Assessment should lead to the richest possible view of the patient as a person with successes and failures”

Martin (1987)

“Learning from the person” (Barker

2004)

Proverb

Seek first to understandthen to be

understood

Assessment Skills

Fundamental, a key competence

Crucial aspect of care

Comprehensive

Impact of unidentified need

Inaccurate assessment

Nursing Assessment

“I'm suggesting you probably need two years postgrad experience before you learn good assessment skills, and I don't mean just summing up a situation.

I mean actually knowing when to persist with something or how to glean information from someone who may not particularly be in the mood to tell you and when it's prudent to withdraw...

If you didn't have those sort of skills you would probably be off work more than you are here with broken noses”

“If you can't assess somebody in 30 seconds you are in big trouble in dangerous or difficult situations”

Aims of Assessment

Detailed description of circumstances and problems

Clear description of current symptoms

Comprehensive risk assessment

Social circumstances and Support networks

Views of significant others

Care planning and Evaluation

Whole lived experience

Physiological

Biological

Behavioural

Social

Spiritual (Parse 1995)

The Patient as the ExpertTwo way process – encourage collaboration

The person behind the patient

Their perception of their world and themselves

Values and Goals

Empathy

Unbiased

Approaches to AssessmentFormal – structuredInformal – more haphazard

This can often be determined by the patient

BroadNarrow – Selective then Specific

Formal – more uniformity, questions worked out in advance, reduces assessor bias from prejudices and idiosyncrasies.

Outcome should be the same no matter who completes it.

Informal – no structure, ask questions that are thought to be important, assessor bias and value judgements can influence the kind of information collected. May be better suited to someone talkative, articulate.

Use of standardized rating scales.

Be aware of influential factors – culture, family, biological state, environment.

Peplau, Robinson, Ward – share the view that mental health nursing is concerned to address the person’s human response to problems involving his relationship to himself and others.

Funnelling (Hawkins 1986)

Broad Assessment

All areas of functioning

Use of open questions

Selective Assessment

Identify relevant symptoms and problems

Use of leading or selecting questions

Specific Assessment

Focus on fine detail

Use of closed questions

Approaches

Funnel Sequence Inverted Funnel

Sequence

Tunnel Sequence

Erratic Sequence

Process

Why am I doing this assessment?

What is the aim of the assessment?

What should I assess?

How will I get the information?

How will I decide what that info means?

Different conditions?

Assessment – Step by Step

1. Method – Kipling, ongoing process, joint assessment

2. Information – attentive, individual, past, present & future plans

3. Analysis – all available info, patient’s perspective

4. Picture – formulation, streamline, incl potential improvement

5. Judgement – focus, priority, collaboration, honesty

Barker (2004)

Assessment Framework

Who ?

What ?

Where ?

When ? How ?

Why ?

Their names are What and Why and WhenTheir names are What and Why and When

And How and Where and Who”And How and Where and Who”

““I keep six honest serving men, (They taught me all I I keep six honest serving men, (They taught me all I know):know):

Methods

InterviewDirect observationMeasurement – using valid Assessment Tools

e.g. rating scales, questionnaires

All are aimed at collecting information on: Measurement – scale and size

Clarification – context and conditions

Explanation – purpose and function

Variation of the circumstances – scale and frequency

Proverb

To listen well is as powerfula means of influence

as to talk well

InterviewMain goals – descriptive, diagnostic, therapeutic

Engaging and Relationship building, communication skills

Trust building

Patient’s views

Professional collaboration

Problem identification – remember funnelling

Problem resolution

ObservationAssessment and Management

Overt v Covert

Obtain precise description

Individual aspects

Social aspects

Mind reading and inference

““I think it's actually quite holistic really. If you walk into the I think it's actually quite holistic really. If you walk into the house, you immediately notice what the house is like, is it house, you immediately notice what the house is like, is it different from normal, does she wash the dishes, you know different from normal, does she wash the dishes, you know that sort of thing, how well is the person dressed, you that sort of thing, how well is the person dressed, you know, that's always a good sign, look at their children if know, that's always a good sign, look at their children if they've got children.they've got children.

But just immediately you assess the physical environment But just immediately you assess the physical environment and the physical appearance of the person. and the physical appearance of the person.

Then I think if you're going to check their mental state Then I think if you're going to check their mental state you'd sit down and chat about it, and you do get on to the you'd sit down and chat about it, and you do get on to the mental health assessment and do that, and medication, mental health assessment and do that, and medication, side-effects, whether they've got any other physical side-effects, whether they've got any other physical problems that they're having, any other social problems problems that they're having, any other social problems that they're having with regards to their children and all that they're having with regards to their children and all sorts of things, you know partner problems, also help sorts of things, you know partner problems, also help identify areas where they can fit into community facilities.”identify areas where they can fit into community facilities.”

Nursing Assessment

Measurement

Provide a baseline

Can help with diagnosis

Broad or Specific

Validated and evidence based

Inter-rater and Test-retest Reliability

Self assessment - diaries

Assessment Tools

Mini Mental State Examination (MMSE)

Beck Depression Inventory

Hospital Anxiety and Depression (HAD) Scale

CAGE Questionnaire

MMSE30 point questionnaire which covers 8 domains:

OrientationRegistrationAttention and calculationRecallLanguageReading and writing3 stage commandConstruction

Beck Depression Inventory

21 item scale each rated from 0 – 3 to assess the intensity of depression:MoodOutlookSatisfaction and InterestSelf-esteemSleep appetite and weight lossSexual habits

Hospital Anxiety and Depression (HAD) Scale

I feel tense or wound up I still enjoy the things I used to enjoy I get a sort of frightened feeling as if something awful is about to happenI can laugh and see the funny side of thingsWorrying thoughts go through my mindI feel cheerfulI can sit at ease and feel relaxedI feel as if I am slowed downI get a sort of frightened feeling like butterflies in the stomachI have lost interest in my appearanceI feel restless as if I have to be on the moveI look forward with enjoyment to thingsI get sudden feelings of panicI can enjoy a good book or radio or TV programme

Anxiety (Odd) /21 Depression (Even) /21

CAGE Questionnaire

Alcohol dependence is likely if the patient gives 2 or more positive answers:

Have you ever felt you should CUT down your drinking?Have people ANNOYED you by criticising your drinking?Have you ever felt bad or GUILTY about your drinking?Have you ever had a drink first think in the morning to steady your nerves or get rid of a hangover (EYE- opener)?

Bernadt et al have claimed that the CAGE test (scores >=2) has a sensitivity of 93% and a specificity of 76% for the identification of problem drinkers.

AccountabilityClearly recorded, legibly, concisely, unambiguously

Signed and dated

Evidence of patient’s/carer’s perceptions

Observations supported with appropriate evidence

All sources of info have been tapped, info sharing

Sufficient info to plan care

Assessment complete, if not are reasons noted

Conclusion

What assessment is

Why it is necessary

Mental Health Nurse’s role

Approaches, process and methods

What to do with the information

References

Barker PJ (2004) Assessment in Psychiatric and Mental Health Nursing Stanley Thornes: Cheltenham

Barker PJ (ed) (2003) Psychiatric and Mental Health Nursing, The craft of caring. (Section Two) Arnold: London

Fletcher SC (2002) The Tidal Model: the questions answered. Mental Health Practice. Vol 5 (8): pp 29 – 37.

Norman I, Ryrie I (2004) The Art and Science of Mental Health Nursing Open University Press: Maidenhead

O’Carroll, M., Park, A. (2007) “Assessment” Essential Mental Health Nursing Skills. Mosby Elsevier: London pp 125-146