Nursing Component Task
Nursing procedures & clinical learning

Community Mental Health Nursing (RCMN)

ASSESSMENT OF MENTAL HEALTH STATUS OF A CLIENT

This is a clinical assessment process that is used by the RCPN to determine the client current state of mind under the domains of appearance, attitude, behaviour, mood, affect, speech, thought process, thought content, perception, cognition, insight and judgment.

Purpose

  • Provides a baseline data which enables the RCPN to monitor and evaluate the progress of client's response to treatment
  • Obtain useful information in formulating a diagnosis
  • Plan effective nursing and medical care

Indications

  • Determining the client's current state of mind across the assessment domains.
  • Obtaining baseline data to monitor and evaluate the client's response to treatment.
  • Formulating a diagnosis and planning effective nursing and medical care.

Equipment

  • Manual/electronic area register/ records of the client
  • Chairs

Preparation

  • Ensure a safe and conducive environment for the interaction.
  • Prepare chairs and the client's records before the assessment.

Procedure steps

  • Ensure a safe and conducive environment for the interaction
  • Use simple and clear language that the client understands
  • Establish rapport and explain the reason for the interaction
  • Ensure privacy and assure client of confidentiality
  • Assess client under the following domains:
  • Appearance - grooming, facial expression, deformity, etc.
  • Attitude - cooperative, hostile, overly anxious etc.
  • Behaviour - biting of nails, chewing of lips, fidgeting, etc.
  • Mood - irritable, euphoria, dépression, etc.
  • Affect - congruence, blunt, flat, etc.
  • Speech - rate, coherent, stuttering, etc.
  • Thought - process; word salad, thought block, flight of ideas etc.
  • Thought content - delusions, suicidal ideation, magical ideation, etc.
  • Perception - hallucinations, illusion, depersonalization, etc.
  • Cognition - remembering, knowing, problem solving, etc.
  • Insight - awareness of illness
  • Judgment - arithmetic ability, decision making, etc.
  • Express appreciation to client for his cooperation
  • Document the interaction and observations in the report book

Precautions

  • Ensure a safe and conducive environment for the interaction.
  • Use simple and clear language that the client understands.
  • Ensure privacy and assure the client of confidentiality.
  • Document observations objectively and refer concerns beyond scope as appropriate.

Aftercare

  • Express appreciation to the client for his or her cooperation.
  • Document the interaction and observations in the report book.

Nursing considerations

  • Assess the client under the domains of appearance, attitude, behaviour, mood, affect, speech, thought process, thought content, perception, cognition, insight and judgement.
  • Record baseline data to enable monitoring and evaluation of the client's response to treatment.

Patient education

  • Explain the reason for the interaction and reassure the client of confidentiality.

Documentation

  • Document the interaction and observations in the report book.

References and further reading

Educational resource only. Follow current Nursing and Midwifery Council guidance, local institutional protocols, scope of practice, and clinical supervision.

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