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All About Assessment: Highlights from APNA Evidence-Based Resources

By APNA Bloggers posted 12-11-2017 10:00 AM

  
The Basics of Assessment
From Psychiatric-Mental Health Nursing: Scope and Standards of Practice

The Psychiatric-Mental Health Nursing: Scope and Standards of Practice lays out the guidelines for assessment, which includes collecting and synthesizing data from the “health care consumer, family, other healthcare providers, and other consumer-identified support systems”. It also means “focusing on the uniqueness of the person”, using effective clinical interviewing skills to develop a therapeutic relationship, and using “therapeutic principles to understand and make inferences about the healthcare consumer’s emotions, thoughts, behaviors, and conditions”.


Full Biopsychosocial Assessment for Substance Use Disorders

From Effective Treatments for Opioid Use Disorders: Educating and Empowering Nurses During an Epidemic

A full biopsychosocial assessment for substance use disorders includes patient engagement through motivational interviewing, gathering information, screening for immediate medical and psychiatric needs, and identification of individual strengths. According to the 2015 Veterans Association Department of Defense Joint Guidelines on Substance Use Disorders, necessary assessment components are the patient’s: past treatment response, perspective of the problem, motivational level, treatment preferences and longterm goals.


Suicide Risk Assessment

From APNA Psychiatric-Mental Health Nurse Essential Competencies for Assessment and Management of Individuals at Risk for Suicide

These competencies lay out an evidence-based process for the psychiatric-mental health nurse, including a risk assessment for self-directed violence (non-suicidal and suicidal) both upon admission and on an ongoing basis during the patient’s hospitalization – even in the absence of expressed suicidality. The nurse considers many factors, from the distinction between self-directed violence without the intent to die and self-directed violence with the intent to die, to the patient’s motivation to minimize and/or exaggerate risk. The nurse synthesizes information on a continuous basis, making “a clinical judgement of the risk that the patient will attempt suicide or die as a result of suicide” in the short term
and long term. These assessments should be documented initially and also, along with interventions, during hospitalization at key times.


Assessing Persons with Bipolar Disorder

From Module 1 of APNA Transitions in Practice Certificate Program

When completing a nursing assessment of a client diagnosed with a Bipolar Spectrum Disorder, the nursing priority should always be to assess the patient’s risk for suicide. The 15% rate of suicide amongst individuals with bipolar disorder is about 30 times higher than that of the general population. Maslow’s hierarchy of needs guides nurses to first establish safety (by determining suicidality) then to attend to the details of nursing care for persons with bipolar disorder. The APNA Transitions in Practice Certificate Program covers foundational evidence-based knowledge you need, such as this, to provide safe and effective care.


Spiritual Assessment

From the APNA Undergraduate Education Faculty Toolkit

A spiritual assessment aids in the creation of a culturally sensitive care plan promoting care that meets the needs of patients from diverse cultural, racial, and ethnic backgrounds. One effective standardized scale is the FICA Spiritual History Tool*. In this mnemonic, F refers to faith and belief - whether a person has spiritual beliefs that help them cope with stress and/or what gives their life meaning. I is to determine the importance of spiritual belief in the person’s life and its role in their health. C is for community – if the person has a community that provides support and is important to them. A is to assess how this person would like the provider to address spiritual components in their healthcare.
*Information from https://smhs.gwu.edu/gwish/clinical/fica/spiritual-history-tool


Violence Prevention through Assessment

From the APNA Position Statement on Violence Prevention
The goal of violence prevention is to decrease risk factors and increase protective factors. Each PMH nurse must solicit specific data about factors associated with violence when assessing an individual or family seeking care. Agitation (a notable risk factor) often precedes violence. Studies show that recognizing early warning signs of agitation can preempt violence.
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