Mental Health Assessment Skills

Therapists who work with mentally or emotionally troubled individuals often use the fifth edition of the DSM, DSM-5, to aid in diagnosis and help guide clinical practice. One of the tools used in the DSM-5 is the World Health Organization’s Disability Assessment Tool (WHODAS 2.0; Table 9.1). The diagnosis of mental health problems remains the responsibility of the physician, but nurses and other care providers should be familiar with the multiaxial system of psychiatric assessment. Several tools are available for assessing mental status. One example of a mental health assessment tool is seen in Appendix A.

Each step of the nursing (therapeutic) process is designed to support goal-directed care for clients (Stuart, 2014). The process is an organizational framework for effective care and consists of five steps: assessment, diagnosis, planning, intervention, and evaluation. Using this process encourages us to focus on the client and develop appropriate and effective care.

The first step, assessment, is the data collection step. Bits of information relating to the client are collected from every possible source. Medical records are reviewed, a history is obtained, and observations are made; discussions with family members or friends add to the database. Soon a picture of the client begins to emerge. Using the mass of collected information as a database, care providers plan care based on the needs, abilities, preferences, and concerns of the client.

Next, data are organized into related areas, and problems are identified. Each problem is then examined in detail, and problem statements and nursing diagnoses are developed. (Medical diagnoses and interventions relate to the client’s physical or mental dysfunctions; nursing diagnoses and interventions focus on how the client’s problems affect his or her ability to carry out the activities of daily living.) Client needs are also considered when problem statements are being developed.

During the planning phase, specific short-term and long-term goals are developed. The outcome of each problem is projected by identifying behaviors that would indicate the problem is solved. These “expected outcomes” are then used to monitor the client’s progress. Therapeutic actions (interventions) are planned using goals and expected outcomes. Then a written care plan is developed.

The intervention phase includes the actual delivery of the planned actions. Therapeutic interventions, carried out by all mental health care team members, guide clients toward their goals. Client responses to each intervention are monitored. Work to keep an open mind when observing the client’s responses to care, and remember that many reactions are culturally determined.

The clinical judgment model is another way of establishing and supporting goal-directed care. It includes critical thinking and reasoning skills. The use of the clinical judgment model involves these skills: processing information allows the nurse to identify important cues about the client’s condition. Thinking critically helps the nurse recognize relevant data, prioritize concerns, and choose the best course of action. Using problem-solving skills and applying relevant knowledge encourage the nurse to reflect on the situation and evaluate the evidence for planning safe and effective care.

To develop good clinical judgment, a nurse uses six skills. To recognize cues, the nurse determines which data are of immediate concern and what is relevant or irrelevant. To analyze cues, the client’s history and situation are considered in relation to the assessed information. All possible issues relating to the client are determined when the nurse prioritizes hypotheses. The desired outcomes of care are identified and specific actions are planned in the generate solutions phase. During the take action phase, the nurse delivers care, provides health education, and works with other health care providers to improve the client’s condition. Last, the evaluate outcomes phase compares the client’s actual outcomes with expected outcomes of care. If the client’s condition does not change, or it declines, the nurse must decide which nursing actions are ineffective or made no difference and repeat the process.

Clients are involved as partners in care. Although some individuals are unable or too discouraged to make decisions, most are capable of participating in some part of their care. Caregivers help clients problem-solve by involving them in the care planning process. Evaluation of both clients’ and caregivers’ actions allows for adjustments in the dynamic process known as “treatment.” Use of the nursing (therapeutic) process and clinical judgment model requires knowledge, experience, and the practice of good judgment. Experience grows with each application of the process, and sound judgment is gained by looking at every possible side of a problem before arriving at a decision. The nursing (therapeutic) process serves as a tool for defining and solving client problems, but the tool is only as effective as the practitioner. The art of choosing the best course of action must be carefully practiced. Let the “do no harm” principle guide you as you grow.

The term data collection refers to a variety of activities designed to gather information about a certain subject. Data-collecting methods for care providers include interviews, observational techniques, and rating scales and inventories. An interview is a meeting of people with the purpose of obtaining or exchanging information (Keltner and Steele, 2019). Interviews can be formal and highly structured, or informal and casual. Information gathered from formal interviews is usually documented on a standardized form. The interview is an excellent method for obtaining information and it serves as the starting point for building the therapeutic relationship. Informal interviews usually occur casually and provide great opportunities to learn more about clients and their families. Caregivers use informal interview techniques when they investigate client problems or explore certain topics.

Data-gathering through observational techniques is commonly used. Observation is the process of purposeful looking. When using observation as a data-gathering technique, caregivers must take care to be objective; personal bias or attitudes can alter one’s perceptions and affect the objectivity of the observations. The use of observation is an excellent method for gathering information when the caregiver can remain impartial and does not pass judgment.

Physical assessment skills are important to the data-gathering process. They are used to gather data, investigate changes in physical conditions, and evaluate the effectiveness of therapeutic interventions. Physical examination skills are special methods for obtaining information about the body’s functioning. The technique of observation is called inspection, which means a purposeful examination of the body. The skills of auscultation and percussion use the examiner’s sense of hearing to detect sounds within the body. Finally, the technique of palpation requires the sense of touch to draw out information about temperature, texture, and pulsations of the body.

Social workers, psychologists, and other therapists frequently use rating scales and inventories. These are data-gathering tools specifically designed to bring out certain kinds of information. The results are then compared with standardized measurements. Rating scales and inventories can be very useful for focusing on specific aspects of client problems.

The success of any client interview rests on the caregiver’s ability to listen objectively and respond appropriately. To enhance your interviewing skills, follow these guidelines:

Describe the rate, volume, and characteristics of the client’s speech. Note any abnormal speech patterns (see Chapter 10).

Next, turn your attention to the client’s motor activity, gestures, and posture. Observe the client’s physical movements for the level and type of activity, and note any unusual movements or mannerisms. Is the client agitated, tense, restless, lethargic, or relaxed? Are there any tics, grimaces, repeated facial expressions, or tremors? Excessive body movements are seen in individuals with anxiety or mania; they can also result from the use of stimulants or other drugs. Repeated movements or behaviors are seen in clients with obsessive-compulsive disorders, and picking at one’s clothing is often seen in clients with delirium or toxic reactions.

To complete the general description, assess the client’s behavior during the interaction. How did the client relate to you? Was he or she cooperative, hostile, or overly friendly? Did the client appear to trust you? Note whether the verbal messages matched the behaviors. Clients who use unconnected gestures, for example, may be hallucinating.

To assess the client’s emotional state, the care provider considers the client’s mood and affect. Mood is defined as an individual’s overall feelings; it is a subjective factor that can be explained only by the person experiencing it. Usually, people will have a basic mood, although it may change during the day. To illustrate: a basically relaxed and happy person may feel disappointed by an incident during the day but soon forgets and returns to his or her usual happy mood. A person’s mood can range from overwhelming sadness to great elation and joy. These variations are referred to as one’s range of emotion. Affect is the client’s emotional display of the mood being experienced. Table 9.4 explains several kinds of affect. Affect can be categorized as appropriate, inappropriate, pleasurable, or unpleasurable. To assess a client’s affect, ask what he or she is feeling and then observe the reactions. Do the responses to your questions match the subjects being discussed? Is the client overreacting, not reacting at all, or responding inappropriately? Document objective descriptions of the client’s behaviors. Descriptions communicate much more information than does a single medical term.

The category of experiences explores the client’s perceptions, the ways in which he or she experiences the world. An individual’s perceptions are often called one’s frame of reference. In short, a person’s perceptions help determine his or her sense of reality.

People who are having mental health problems may have difficulty in perceiving the same reality as the rest of society. Hallucinations are perceptions that have no external stimulus. The client may hear voices or see things that are not perceived by other people. Hallucinations involving taste, touch, or smell may indicate a physical problem. Visual and auditory hallucinations are associated with schizophrenia, the acute stage of alcohol or drug withdrawal, and organic brain disorders. Alterations in perceptions that have a basis in reality are called illusions. External stimuli are present, but the client perceives them differently, for example, a client who perceives the person walking down the hall as a wolf. If a client is having illusions or hallucinations, ask him or her to describe the experience. Box 9.3 lists several questions that can help explain the client’s experience.

Remember that hallucinations or illusions are very real to the person experiencing them. Caregivers cannot “talk them out of it” or tell them to ignore what they perceive. However, because they are so real, clients usually are willing to describe them when asked.

The “thinking” section of the mental status examination focuses on thought content and processes. Thought content relates to what an individual is thinking. Clients may be experiencing delusions, obsessions, phobias, preoccupations, amnesia, or confabulations.

Disturbances in thought processes relate to how a person thinks—how he or she analyzes the world, connects and organizes information. Disorders of thought processes include blocking, flight of ideas, loose associations, and perseveration. Several disorders of thought processes are listed in Table 9.5.

Another problem of thinking is depersonalization, a feeling of unreality or detachment from oneself or one’s environment. The unreal feelings produce a dreamlike atmosphere that overtakes the individual’s consciousness. One’s body does not feel like one’s own. Events that are dramatic or important are seen with a detached calmness, as if the person were watching instead of participating in reality. Feelings of depersonalization can normally occur when one is anxious, stressed, or very tired. Depersonalization disorders are often seen in clients with severe depression and in some forms of schizophrenia.

Assessment of the client’s thought content and process occurs throughout the entire mental status examination. Are the client’s thoughts based in reality? Are his or her ideas communicated clearly? Do the client’s thoughts follow a logical order? Are any unusual thoughts, preoccupations, or beliefs present? Does the client have any suicidal, violent, or destructive thoughts (American Psychiatric Association, 2018)? Are there any persistent dreams? Does the client believe that someone is intent on harming him or her (feelings of persecution)? Observe the client closely, and listen intently. Much information will be revealed during the course of the interaction.

The sensorium is that part of consciousness that perceives, sorts, and combines information. People with a clear sensorium are oriented to time, place, and person. They are able to use their memories to recall recent and remote information. Levels of consciousness and memory recall help assess a person’s sensorium.

Level of consciousness can be determined by observing the amount of stimuli needed to arouse the client (Table 9.6). If the client cannot be awakened by verbal stimuli, notify your supervisor immediately. If the client is awake, note his or her responses to your questions, the degree of interaction, and the amount of eye contact that is being made.

Memory is the ability to recall past events, experiences, and perceptions. For the purpose of testing, memory is divided into three categories: immediate, recent, and remote memory. Immediate memory is also referred to as recall. To assess it, ask the client to remember three things (e.g., a color, an address, an object). Later in the conversation (after at least 15 minutes have elapsed), ask the client to repeat the three items. Recall can also be tested by having the client repeat a series of numbers within a 10-second period.

Recent memory includes events within the past 2 weeks. Caregivers test recent memory by asking the client to recall the events of the past 24 hours. Loss of recent memory is seen in people with Alzheimer’s disease, anxiety, and depression.

Assessing remote memory involves asking the client questions about his or her place of birth, background, schools attended, and ages of family members. This part of the mental status examination can easily be done during the nursing health history interview. It is sometimes difficult to tell whether the client has accurate memories. Long-term memory loss is seen in clients with organic (physical) problems, conversion disorders, and dissociative disorders.

The level of concentration focuses on the client’s ability to pay attention during the conversation. Calculation tests the ability to do simple math problems. Have the person count rapidly from 1 to 20; perform simple addition, multiplication, and division problems; and subtract 7 from 100, then 7 from 93, and so on. Then ask practical questions such as the number of dimes in $1.90. Note how easily the client becomes distracted during these tasks. People with mental-emotional problems commonly have difficulty with concentration and calculations. These difficulties also occur in people with physical disorders, such as brain tumors, so it is important to assess the client’s ability to concentrate and do simple calculations.

During this phase of the mental status examination, the client’s education level, general knowledge, ability to read, use of vocabulary, and ability to think abstractly are also assessed. General knowledge can be tested by asking the person to name the past five presidents or five large cities. Ask the client about the last grade completed in school.

To determine reading ability, print a command, such as “Close your eyes,” on a piece of paper. Ask the client to read it and follow the directions. During the conversation, also note the client’s choice of words and their use.

Assess the client’s ability to think abstractly by having him or her explain the meaning of several well-known proverbs, such as “a stitch in time saves nine”; “a rolling stone gathers no moss”; “when it rains, it pours”; or “people in glass houses shouldn’t throw stones.” Many people with mental health problems give concrete answers such as, “Moss only grows on the north sides of stones,” or “People who live in glass houses shouldn’t throw stones because it breaks the glass.”

Judgment refers to the ability to evaluate choices and make appropriate decisions. During the health history interview, observe how the client explains personal relationships, his or her job, and economic responsibilities. Assess the client’s judgment by asking questions such as, “What would you do if you …

Judgment is often impaired in people with chemical dependence, intoxication, schizophrenia, intellectual disability, and organic mental disorders. Document the client’s responses using the client’s own words whenever possible.

Insight refers to the client’s understanding of the situation. What is the client’s understanding of the disorder? Questions that help the caregiver assess insight include, “Have you noticed a change in yourself recently?” and, “What do you think is the cause of your anxiety (discomfort)?” Expect clients to have different degrees of insight. For example, a person with an alcohol problem may realize that he or she drinks too much but does not think that it is interfering with family life. Again, be sure to document the client’s statements rather than your opinions.

Although the mental status examination may appear to be a lengthy process, much of it can be performed during the history interview. Checklists that address each area of the examination are available (see Box 9.4 and Appendix A for a copy of the Mental Status Assessment at a Glance).

Care providers often use parts of the mental status examination to assess clients whose mental state changes frequently. For example, the caregiver assesses the hallucinating client for thought content and process at intervals throughout the day.