Assessment of patients, or the understanding of the patient especially in connection with the disease or ailment, assumes special significance in psychiatric nursing, because the responsibility of a psychiatric nurse is not mere care and assistance for curing the disease, as in other cases, but the wholesome care of the patient and restoring normalcy to the patient. The patients requiring psychiatric treatment are generally insane or have some sort of mental disorder and restoring normalcy or near normalcy becomes the ultimate challenge for a psychiatric nurse.
Assessment of the patient, his or her feelings, behavior, attitude, characteristics, mental state and awareness and all such things, gain paramount importance in psychiatric nursing, as these details, though trivial as it may look, provide important clues for formulating the nursing process, diagnosis and evaluation of the course of treatment for the patient as a whole.
Active participation of the patient in the treatment process is essential in psychiatric nursing and invariably requires an extended stay of the patients at the hospital or specialty care centers.
As part of the assessment of the patient, the following details need to be recorded:
The perception of the patient with regard to the facilities in the hospital, the services rendered and the general atmosphere available in the center needs to be ascertained and recorded
General strength of the patient, as perceived by him or her and explained to the psychiatric nurse as part of the therapeutic communication should find place in the assessment. In addition, psychiatric nurse's view about patient's strength can also be included.
The assessment record should include the perception of the disease from the patient's point of view and how he or she copes with the disease. In other words, the efforts put in by the patient to deal with the present ailment or disease needs to be recorded.
Information about the patient's family, the background and historical patterns of behavior in the family members needs to be recorded by gathering information from the patient and his or her close relatives or family members interested in the cure of the patient
Appearance, cultural background and the primary language of the patient
Habits of the patient that include addictions, if any, for smoking, drinking or chewing tobacco or such other things
Level of memory of the patient – such as recent memory and remote memories, as well as orientation of the patient – the place of residence and living
Complete and comprehensive details of the patient's physical systems, as well as nutrition problems, allergies and such other medical issues, if any
Details related to suicidal thoughts, perceptions of hallucinations or delusions, aggression or such other thoughts should also be noted as part of the assessment.
Relationship with family members, present living conditions, communication skills, cognition levels, mood related issues should also find a place in the Assessment
Present standard of living, income earning capability and remuneration, value systems in life, hobbies, interests and spiritual affinity should also be recorded in the assessment form.
Some of the details recorded by the psychiatric nurse might look trivial, but they are essential for further treatment and preparation of nursing plans and diagnosis in association and co-operation of the patient.
