mental health biologic and social assessment

Judith D. Hiett, MSN, RN

Conditions of Use: Creative Commons Attribution-Noncommercial 3.0

Appearance◦ Behavior, mood, grooming, relaxed state,

confidence Level of consciousness

◦ Oriented to time, place, person◦ Memory intact◦ Able to think abstractly

Speech◦ content, thought processes◦ Insight and judgment◦ Self-perception

Understand how stress might alter a client’s internal body functioning◦ Physical exam◦ Neurologic exam◦ Lab results◦ Activities, ability to function, exercise

Sleep patterns disruptions, inability to fall &/or stay asleep, constant

sleeping Nutritional assessment

Lack of appetite, failure to enjoy food, overeating, eating disruptions

Pharmacological assessment What meds is client currently taking that may account

for behavior?

Family history, client lifestyle, life-changing events, presence of social support systems◦ Cultural practices◦ Community resources◦ Spiritual concerns◦ Occupational assessment

Can client continue to work?◦ Economic status

Interaction with others◦ Family communication patterns, level of cohesion,

flexibility, function , and general support◦ Satisfying interpersonal relationships◦ Ability to cope with stress◦ Ability to trust

Conditions of Use: Creative Commons Attribution-Noncommercial 3.0