Component Task: 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.

Aims

·         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

Requirements

·         Manual/electronic area register/ records of the client

·         Chairs

Steps

1.        Ensure a safe and conducive environment for the interaction

2.      Use simple and clear language that the client understands

3.      Establish rapport and explain the reason for the interaction

4.      Ensure privacy and assure client of confidentiality

5.      Assess client under the following domains:

a.      Appearance – grooming, facial expression, deformity, etc.

b.      Attitude – cooperative, hostile, overly anxious etc.

c.      Behaviour – biting of nails, chewing of lips, fidgeting, etc.

d.      Mood – irritable, euphoria, dépression, etc.

e.      Affect – congruence, blunt, flat, etc.

f.        Speech – rate, coherent, stuttering, etc.

g.      Thought – process; word salad, thought block, flight of ideas etc.

h.      Thought content – delusions, suicidal ideation, magical ideation, etc.

i.         Perception – hallucinations, illusion, depersonalization, etc.

j.         Cognition – remembering, knowing, problem solving, etc.

k.       Insight – awareness of illness

l.         Judgment – arithmetic ability, decision making, etc.

6.      Express appreciation to client for his cooperation

7.       Document the interaction and observations in the report book