7.2 General Assessments for Mental Health Conditions

Nursing assessments related to mental health and neurodevelopmental conditions differ from assessments for medical conditions in that there is a greater focus on collecting subjective data. For example, prior to administering a cardiac medication to a client with a heart condition, a nurse will assess objective data such as blood pressure and an apical heart rate to determine the appropriateness of the medication. However, prior to administering an antidepressant, a nurse uses therapeutic communication to ask questions and gather subjective data about how the client is feeling to determine the effectiveness of the medication. The nurse will also observe and document client behaviors, speech, mood, and thought processes as part of the mental health assessment.^[1]

Nurses ask questions to determine how a client is feeling emotionally and perceiving the world. An example of a nurse using therapeutic communication to perform a subjective assessment is, “Tell me more about how you are feeling today.” The nurse also uses general survey techniques such as observing the client for behavioral cues, including their mood, hygiene, appearance, and movements.

Recall the mental health continuum introduced in the “Basic Concepts of Mental Health and Mental Illness” section of the “Mental Health Concepts” chapter, Figure 5.1. Nurses in all health care settings holistically assess clients’ physical, emotional, and mental health, as well as their functioning. They must recognize subtle cues of undiagnosed or poorly managed mental health conditions and communicate their findings with other members of the interprofessional health care team.

When assessing a client’s mental health, the nurse incorporates a variety of assessments, in addition to the traditional physical examination. A comprehensive mental health assessment includes the following components:

• Performing a mental status examination
• Completing a psychosocial assessment
• Reviewing prescribed psychotropic medications (drugs that treat mental health symptoms)
• Screening for suicidal ideation and non-suicidal self-harm
• Assessing for exposure to trauma, violence, and substance misuse
• Identifying coping strategies, including a spiritual assessment
• Reviewing specific laboratory results related to the client’s use of psychotropic and other medications
• Incorporating life span, developmental, and cultural considerations

Mental Status Examination

When conducting a focused assessment on a client’s mental health, a proficient nurse develops a style in which the bulk of the mental status examination is performed through unstructured observations made during the routine physical examination, also referred to as the general survey. When a nurse recognizes cues of possible mental health disorders, such as aberrant behavior or difficulties in day-to-day functioning, a focused mental status examination is performed.

A mental status examination assesses a client’s level of consciousness and orientation, appearance and general behavior, speech, motor activity, affect and mood, thought and perception, attitude and insight, and cognitive abilities. The structured components of a mental status examination are outlined in Table 7.2.

Table 7.2. Mental Status Examination

Licensed practical/vocational nurses (LPN/VNs) may collect data related to a mental status examination and report findings to a registered nurse (RN) for analysis and follow-up. Specially trained nurses called psychiatric-mental health nurse specialists receive additional training in assessing thought and perception disorders associated with severe mental illnesses like bipolar disorder and schizophrenia.

Psychosocial Assessment

A psychosocial assessment (also referred to as a health history) is a component of the nursing assessment that detects risks and identifies treatment opportunities and resources. Psychosocial assessments/health histories typically consist of several components:

• Cultural assessment
• Chief complaint (reason for seeking health care)
• Current and past medical history
• Current medications
• History of previously diagnosed mental health disorders
• Previous hospitalizations
• Educational background
• Occupational background
• Family dynamics
• History of exposure to psychological trauma, violence, or domestic abuse
• Substance use (tobacco, alcohol, recreational drugs, misused prescription drugs)
• Family history of mental illness
• Coping mechanisms
• Functional ability/Activities of daily living
• Spiritual assessment
• Thoughts of suicide, self-harm, or homicide

Additional information about these components is discussed in the following subsections.

Cultural Assessment

While performing a psychosocial assessment, it is important to begin by performing a cultural assessment. The American Psychiatric Association developed evidence-based Cultural Formulation Interview (CFI) questions as a way to incorporate cultural assessment into the care of all clients that enhances clinical understanding and decision-making. The CFI questions are used to clarify key aspects of the presenting clinical problem from the point of view of the individual and other members of the individual’s social network (e.g., family, friends, or others involved in the current problem). This includes the problem’s meaning, potential sources of help, and expectations for health care services.^[2]

CFI questions used with all clients include the following^[3]:

• What brings you here today?
• What troubles you most about this problem?
• Why do you think this is happening to you? What do you think is the cause of this problem?
• Are there any kinds of support that make this problem better, such as support from family, friends, or others?
• Are there any kinds of stressors that make this problem worse, such as difficulties with money or family problems?
• Sometimes aspects of people’s background or identity can make their problem better or worse, such as the communities they belong to, the languages they speak, where they or their family are from, their race or ethnic background, their gender or sexual orientation, or their faith or religion. Are there any aspects of your background or identity that make a difference to this problem?
• Sometimes people have various ways of dealing with problems. What have you done on your own to cope with this problem?
• Often, people look for help from many different sources, including different kinds of doctors, helpers, or healers. In the past, what kinds of treatment, help, advice, or healing have you sought for this problem?
• Has anything prevented you from getting the help you need?
• What kinds of help do you think would be most useful to you at this time for this problem?
• Are there other kinds of help that your family, friends, or other people have suggested that would be helpful for you now?
• Sometimes health care professionals and clients misunderstand each other because they come from different backgrounds or have different expectations. Have you been concerned about misaligned care expectations, and is there anything that we can do to provide you with the care you need?

Findings from the cultural formulation interview are used to individualize a client’s plan of care to their preferences, values, beliefs, and goals.

Reason for Seeking Health Care

It is helpful to obtain the reason why the client is seeking health care in their own words, commonly referred to as the chief complaint. Assessing a client’s chief complaint recognizes that clients are complex beings, with potentially multiple coexisting health needs, but in the client’s view, there is often a pressing issue that requires immediate treatment. Questions used to evaluate a client’s chief complaint are as follows:

• What brought you in today?
• How long has this been going on?
• How is this affecting your day-to-day life?

Thoughts of Suicide or Non-Suicidal Self-Injury

Clients being evaluated or treated for mental health conditions often have symptoms of suicidal ideation (thoughts or plans of killing oneself) or self-injury. Non-suicidal self-injury (NSSI) refers to intentional self-inflicted destruction of body tissue without suicidal intention and for purposes not socially sanctioned. Common forms of NSSI include behaviors such as cutting, burning, scratching, or hitting oneself. NSSI is considered a maladaptive coping strategy without the desire to die. These behaviors are commonly found among adolescents and young adults in psychiatric inpatient settings.^[4] Read additional information about suicide screening and safety interventions in the “Suicide Screening and Safety Interventions” section of this chapter.

Family Dynamics and Family Impact

Family dynamics are included in a psychosocial assessment, especially for children, adolescents, and older adults. Family dynamics refers to the patterns of interactions among relatives, their roles and relationships, and the various factors that shape their interactions. Because family members rely on each other for emotional, physical, and economic support, they are primary sources of relationship security or stress. Family dynamics and the quality of family relationships can have either a positive or negative impact on an individual member’s physical and mental health.^[5]

Diagnosis of severe mental illness in a client’s family member, such as schizophrenia, bipolar disorder, and major depression, can seriously impair family functioning and role performance. Research indicates a multigenerational impact of severe mental illness on family members, including parents, spouses, children, grandparents, and siblings, with a substantial toll on their social relationships, employment and income, and psychological well-being. Psychosocial impacts on family members may include a strained family environment, food insecurity, poor school performance, and higher divorce rate.^[6] Children of parents with severe mental illness have a higher risk of developing physical and mental illnesses for a variety of reasons, including the burden of caring for ill parents, genetic vulnerability, financial difficulties, and stigma.^[7] Family members of people diagnosed with severe mental illness have worse physical health and seek more medical care than those families without severe mental illness.^[8] The impact of severe mental illness is considered an adverse childhood experience (ACE) that is linked to an increased risk of developing long-term physical and mental health problems such as heart disease, lung disease, liver disease, depression, and anxiety. Unhealthy family dynamics also correlate with an increased risk of substance use and addiction among adolescents.^[9]

Effectively assessing and addressing the impact of family dynamics on a client’s mental health often requires an interprofessional team, including nurses, physicians, social workers, and therapists. Nurses are in a unique position to observe and document family interaction patterns and relationships because they are in frequent contact with family members.^[10] Nurses can also help reduce the impact of unhealthy family dynamics by referring clients and affected family members to counseling and support groups, as well as helping them navigate the health care system.

Spiritual Assessment

Spiritual assessment is included in a psychosocial assessment. It is common for people in the process of recovery from mental health disorders and substance use to search for spiritual support. Spirituality includes a sense of connection to something larger than oneself and typically involves a search for meaning and purpose in life. Basic questions used to assess spirituality include the following^[11],[12]:

• Who or what provides you with strength or hope?
• How do you express your spirituality?
• What spiritual needs can we help you meet during this health care experience?

Over the past decade, research has demonstrated the importance of spirituality in health care. Spiritual distress is common in clients experiencing chronic illness, and nurses teach individuals how to use positive coping strategies to deal with these life events. Addressing a client’s spirituality and advocating for spiritual care have been shown to improve clients’ health and quality of life, including how they experience pain, cope with stress and suffering associated with serious chronic illness, and approach end-of-life issues.^[13],[14]

The FICA Spiritual History Tool© is a common tool used to gather information about a client’s spiritual history and preferences. FICA© is a mnemonic for Faith, Importance, Community, and Address in Care.^[15] Read more about the FICA© tool in the following box.

Based on the spiritual assessment findings, nurses may refer clients to agency chaplains or to the client’s religious leaders for spiritual support to enhance coping.

Life Span Considerations

Life span considerations influence assessments, nursing care planning, and interventions. Mental health disorders occur across the life span, from the very young to the very old, and developmental stages must be considered when identifying and treating impairments. Assessments and interventions must be individualized to the age and developmental level of the client. Development encompasses physical, social, and cognitive changes that occur continuously throughout one’s life. See Figure 7.1^[16] for an illustration of development through the human life cycle.