Case Study, Mohr

CHAPTER 10, the Interview and Assessment Process

In completing the case study, students will be addressing the following learning objective:

Describe essential elements to include in psychiatric interviews and the assessment process.

The student nurse is accompanying the psychiatric nurse during the nursing interview and assessment of a newly admitted patient. The psychiatric nurse told the student that preparation with subjective and objective data collection is an important part of the process. The nurse explains that assessment has reference to the interviewer's interpretation and prioritization of all data for the client. The nurse must have self-awareness and self-knowledge to be objective and avoid influencing the responses of the client. Anxiety on the part of the nurse may limit the ability for thorough data collection and interpretation. Anxiety in the nurse may evoke anxiety on the part of the client.

The psychiatric nurse stressed that a process recording, or written analysis of the interaction between the client and nurse, is essential for nurses to recognize the effects of their communication style in the assessment process. A review of the client's history is important, and a private setting for the interview is necessary. The content of the nursing assessment should include the ability and reliability of the client's response to questions of the interviewer and the skill of the nurse in identification of relevant facts. The nurse should discuss with the client prior health history, any present illness, and the reason for seeking healthcare at this time. Medication history with compliance and allergies of the client require investigation. Substance use by the client, past illnesses, and family history need exploration.

(Learning Objective: 2)

a The student nurse asked the clinical psychiatric nurse practitioner to explain what she considered the most essential part of the assessment process. How should the psychiatric nurse respond to the student's question? Explain your answer.

Mental Status Examination (MSE) is the most important assessment tools a psychiatrist uses to obtain information to make an accurate diagnosis. It is used to test the cognitive function of a patient and it reflects a snapshot of a person's psychological functioning at a given point in time.