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INTRODUCTION

“Peace begins with a smile.”

–Mother Teresa

OBJECTIVES

  • Perform a legal status assessment

  • Assess the patient’s physical appearance

  • Evaluate the patient’s alertness, orientation, behavior, attitude, affect, and mood

  • Analyze the patient’s thought processes, thought content, attention, concentration, and memory

  • Appraise the patient’s judgment, insight, and intellect

  • Note hallucinations and delusions

  • Assess speech and motor activity

  • Assess other issues to evaluate mental status

  • Perform a risk assessment

  • Formulate a de-escalation plan

New nurses often wonder when violence prevention truly begins. The answer is that it starts on the very first day a patient enters a healthcare facility, with a well-designed mental status assessment upon admission. This assessment gives healthcare professionals the information they need to safely care for the patient. It represents the single most important step in the clinical evaluation of an individual who suffers from or is suspected of having a mental disorder.

A mental status assessment is a person-to-person interview conducted by nursing staff as part of a comprehensive physical and psychosocial assessment. Conducting this assessment involves asking patients questions and noting their answers, while also making visual observations. The results of the assessment are recorded and documented in the patients’ written or electronic health record and communicated in a unit report. In addition, findings are reported to the physician or psychiatrist in charge after admission for appropriate follow-up and intervention as needed.

NOTE

A strong clinical admission assessment is one of the most vital interventions to prevent healthcare violence (Singh, Fazel, Gueorguieva, & Buchanan, 2014).

Psychiatric facilities have long completed mental status and de-escalation assessments on all patients admitted to their facilities. In fact, The Joint Commission requires these assessments for mental health facilities. This is because many patients arrive at mental health facilities with a history of violence. Indeed, it’s often the case that a patient’s violent behavior is the reason for requiring treatment (Damon, Matthews, Sheehan, & Uebelacker, 2012). Recently, some healthcare facilities of other types have begun performing similar assessments to identify those at risk for escalation.

Mental status assessments may vary in their content. Generally speaking, however, a mental status assessment includes an evaluation of the patient’s physical appearance; alertness, orientation, behavior, attitude, affect, and mood; thought processes, thought content, attention, concentration, and memory; judgment, insight, and intellect; whether the patient is experiencing hallucinations or delusions; and the patient’s speech and motor activity (American Psychiatric Association [APA], 2013; Zuckerman, 2005). A mental status assessment might also involve evaluating a patient’s legal status. mcknight1_c10_fig001 shows a template for a standard mental status assessment.

FIGURE 10.1

A template for a standard mental status assessment.

In addition to the mental status assessment, nurses should conduct various risk assessments to determine the likelihood that the patient will hurt himself or someone else and work ...

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