BICOL UNIVERSITY POLANGUI

NURSING DEPARTMENT

NCM 117 – CARE OF CLIENTS WITH MALADAPTIVE BEHAVIOR PATTERNS, ACUTE AND CHRONIC
WORKSHEET NO. 4
MENTAL HEALTH ASSESSMENT

Aubrey Nicole S. Ante Apr 28, 2023

Name of Student Date
BSN 3-A
Class Score

Learning Objective
▪ Identify categories used to assess the client’s mental health status.

▪ Formulate questions to obtain information in each category.

▪ Describe the client’s functioning in terms of self-concept and roles.

Scenario
You are a psychiatric nurse working in a community mental health clinic. One of your regular
patients, John, has missed several appointments and has not been responding to your phone calls or
messages. You become increasingly concerned about John’s well-being and decide to visit him at his
home to conduct a mental health assessment.
Upon arriving at John’s home, you notice that he appears disheveled and is not making eye
contact with you. You ask John how he has been feeling lately, and he responds with short, vague
answers. When you ask John if he has been taking his medication as prescribed, he becomes defensive
and starts to raise his voice.
As you continue the assessment, you notice that John’s mood is low, and he expresses feelings of
hopelessness and worthlessness. You also observe that he has lost weight and has been neglecting his
personal hygiene.
Based on your assessment, you determine that John may be at an increased risk of suicide and
decide to take immediate action to ensure his safety.

Activity. Refer to the above scenario and provide the answers to the questions below.

1. Based on the scenario, select mental health assessment tools that may be used for John. Refer to the
Mental Health Assessment Tools Second Edition uploaded in Google Classroom.
Tool Why is this an appropriate tool(s) to use? Give a
brief and concise discussion.

● BDI is widely used to screen for

● Beck’s Depression Inventory (BDI) depression and to measure behavioral

● Beck’s Suicidal Intent Scale (BSIS)
● Beck’s Hopelessness Scale (BHS)
manifestations and severity of
depression.
● BSIS is an evaluation of suicidal thinking
that helps identify individuals at risk. It
also helps measure a broad spectrum of
attitudes and behaviors.
● BHS measures the extent of the
respondent's negative attitudes, or
pessimism, about the future.

2. Based on assessment data, identify five (5) NANDA-I diagnoses and develop a care plan for each.

● Risk for suicide related to changes in behavior and attitude.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Risk for -Patient will -Present a -Structure -Patient

data: suicide remain safe positive statements and remained safe
related to from suicide attitude. actions in a from suicide or
-Shows changes in or self-injury positive “can do” self-injury
feelings of behavior way instead of
hopelessness -Patient will “do not.” An -Patient
and
and identify example is “You identified
attitude.
worthlessness factors can go for a walk factors
contributing today” or “You contributing to
-Being to thoughts of get to see your thoughts of
defensive. suicide family suicide
tomorrow.”
-Short-temper -Patient will -Patient
ed. participate in participated in
therapy -Acknowledge -The nurse can therapy
-Shows sessions and suicide and acknowledge sessions and
non-committa willingly consequences. suicide as an willingly
l behavior. attempt to option while also attempt to
discussing the
change change
-Sadness reality of that
depression depression
option and its
symptoms consequences. symptoms
Inquire about
how suicide will
solve the
patient’s
problems and
offer
alternatives.
-Administer -Medications
prescribed such as
medications. antidepressants,
benzodiazepines
, and
antipsychotics
should be given
in a controlled
and monitored
setting.

-Promote -If in an
safety. inpatient
behavioral
health unit, the
patient may
require 1:1
supervision to
ensure safety.
Items that could
be used to harm
themselves such
as clothing
items, cords, and
sharp objects
should be
removed.
-Continually
re-evaluate -Especially after
suicide risk. mood changes
and at discharge
as a patient who
is feeling better
is at the highest
risk for suicide
because they
may now have
the energy to
carry out their
suicide.
 ● Self-care deficit related to depression as evidenced by weight loss and neglect towards
personal hygiene.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Self-care -The patient Personal -The patient

data: deficit related will groom and Hygiene was groomed
to depression dress and dressed
-Appears as evidenced appropriately -Encourage the -Being clean appropriately
disheveled. by weight loss with help from use of soap, and with help of
and neglect nursing staff washcloths, well-groomed nursing staff
-Weight loss. toothbrushes, can
towards and/or family. and/or family.
shaving temporarily
personal
-Neglect -The patient equipment, increase -The patient
towards hygiene. make-up, etc. self-esteem.
will gain 1 gained 1
personal pound a week pound a week
hygiene. with -Give -Slowed with
step-by-step thinking and
encouragemen encouragemen
reminders such difficulty
t from family, t from family,
as “Brush the concentrating
significant teeth" “Clean make significant
others, and/or the outer organizing others, and/or
staff if surfaces of simple tasks staff.
significant your upper difficult.
-The patient
weight loss is teeth, then
demonstrated
noted. your lower
teeth.” progress in the
-The patient maintenance
will Weight of adequate
demonstrate Management hygiene and
progress in the was
maintenance -Weight the -Give the appropriately
of adequate client weekly information groomed and
hygiene and and observe needed for dressed
be the eating revising the (shave/makeu
appropriately patterns of the intervention. p, clothes
groomed and client. clean and
-Encourage -Increases
dressed neat).
eating with socialization,
(shave/makeu
others. and decreases -The patient
p, clothes focus on food. gradually
clean and
returned to
neat). -Serve foods or -Clients are weight
drinks the more likely to
-The patient consistent for
client likes. eat foods they
will gradually height and age
like.
return to or baseline
 weight -Encourage -Minimize before the
consistent small, weight loss, illness.
with height high-calorie, constipation,
and age or and and
baseline high-protein dehydration.
before the snacks and
illness. fluids
frequently
throughout the
day and
evening if
weight loss is
noted.

● Impaired Social Interaction related to lack of energy and motivation as evidenced by

incompliance to appointments and inability to meet basic needs and role expectations.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Impaired -The patient - Initially, -Depressed -The patient

data: Social will comply provide people lack complied with
Interaction with activities that concentration appointments.
-Does not related to lack appointments. require and memory.
show interest of energy and minimal Activities that -The patient
in answering motivation as -The patient concentration have no “right identified
calls. evidenced by will identify (e.g., drawing, or wrong” or feelings that
incompliance feelings that playing simple “winner or lead to poor
-Does not to lead to poor board games). loser” social
comply with appointment social minimize interactions.
appointments and inability to interactions. opportunities -The patient
in the clinic. meet basic for the client interacted
needs and role -The patient to put himself with
expectations. will interact down. family/friends/
with - Involve the -Such peers.
family/friends/ client in gross activities will
peers. motor aid in relieving -The patient
activities that tensions and participated in
-The patient call for very might help in certain
will participate little elevating the community
in certain concentration mood. social activities
community (e.g., walking). (e.g., leisure
social activities -Maximizes
-When the the potential
(e.g., leisure client is in the for activity, church
activity, church most interactions member).
member). depressed while
state, Involve minimizing -The patient
-The patient the client in anxiety levels. participated in
will participate one-to-one one activity by
in one activity activity. the end of the
by the end of -Socialization day.
the day. - Eventually minimizes
involve the feelings of -The patient
-The patient client in group isolation. discussedm
will discuss activities (e.g., Genuine two-three
two-three group regard for alternative
alternative discussions, art others can ways to take
ways to take therapy, dance increase when feeling
when feeling therapy). feelings of the need to
the need to self-worth. withdraw.
withdraw.
-Contact with -The patient
-The patient -Eventually others identified
will identify maximize the distracts the two-three
two-three client’s client from personal
personal contacts with self-preoccup behaviors that
behaviors that others (first ation. might
one other, then
might discourage
two others,
discourage others from
etc.).
others from -The client seeking
seeking -Refer the and the family contact.
contact. client and can gain -The patient
family to tremendous
-The patient eventually
self-help support and
will eventually voluntarily
groups in the insight from
voluntarily community. people attended
attend sharing their individual/gro
individual/gro experiences. up therapeutic
up therapeutic meetings
meetings within a
within a therapeutic
therapeutic milieu
milieu (community or
(community or hospital).
hospital).
-The patient
-The patient verbalized that
will verbalize he enjoys
that he enjoys interacting
 interacting with others in
with others in activities and
activities and one-on-one
one-on-one interactions to
interactions to the extent
the extent they did
they did before
before becoming
becoming depressed.
depressed.
-The patient
-The patient stated and
will state and demonstrated
demonstrate progress in the
progress in the resumption of
resumption of sustaining
sustaining relationships
relationships with friends
with friends and family
and family members
members within one
within one month.
month.

● Hopelessness related to social isolation as evidenced by decreased verbalization and lack of

eye contact.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Hopelessness -Patient will -Build a -A trusting, -Patient

data: related to verbalize their trusting supportive verbalized
social isolation feelings relationship. rapport will their feelings
-Responds as evidenced regarding allow the regarding
with short, by feelings of hopelessness patient a safe hopelessness
vague worthlessness space to
answers. -Patient will address their -Patient
and
identify coping thoughts and identified
melancholy,
-Appears low mechanisms to feelings. coping
in mood. decreased -Help the -The patient
improve mechanisms to
verbalization patient may have a
feelings of improve
-Not making and lack of eye recognize their skewed
hopelessness feelings of
eye contact. contact. control. understanding
hopelessness
-Patient will of what is or
set short and isn’t in their
long-term control. Help -Patient had
goals to the patient set short and
develop and recognize long-term
maintain a misconceptio goals to
positive ns and accept develop and
outlook only what is maintain a
within their
positive
ability to
outlook
change.
-Encourage -Major
counseling/the depression
rapy. requires the
intervention
of a trained
mental health
professional.
Psychologists
can help with
acceptance
and
adaptation to
life changes,
help set
realistic goals,
and help
develop skills
to cope.
-Help identify -Assist the
positive coping patient in
behaviors. identifying
coping
behaviors
they have
used in the
past that were
effective or
activities they
once enjoyed
that can help
now.
 ● Ineffective coping related to intense emotional state and negative attitudes towards health
behavior as evidenced by anger and hostility.

ASSESSMENT DIAGNOSIS PLANNING INTERVENTION RATIONALE EVALUATION

Objective Ineffective -The patient - Approach the -Enhances -The patient

data: coping related will have an client in a feelings of has an
to intense increase in the consistent security and increase in the
-Easily emotional frequency of manner in all provides frequency of
angered. state and expressing interactions. structure. expressing
negative needs directly Exceptions needs directly
-Irritable. encourage
attitudes without without
manipulative
towards health ulterior ulterior
-Sudden behavior.
change of behavior as motives. -Make a clear -Helps motives.
mood. evidenced by and concrete minimize
-The patient -The patient
anger and written plan of manipulations
will learn and learned and
hostility. care so other and might
master skills mastered skills
staff can follow. help
that facilitate that facilitate
encourage
functional cooperation. functional
behavior. behavior.

-The patient - If feasible, -If goals and -The patient

devise a care interventions
will demonstrated
plan with the are agreed
demonstrate an increase in
client. upon,
an increase in cooperation impulse
impulse with the plan control.
control. is optimized. -The patient
- Focus on the -Defuses
-The patient demonstrated
client’s tension and
will the use of a
underlying opens up
demonstrate feelings. productive newly learned
the use of a interaction. coping skill to
newly learned -Understand -Often acting modify anxiety
coping skill to underlying out behaviors and
modify anxiety feelings stem from frustration.
and prompting underlying
inappropriate feelings of -The patient
frustration.
behaviors. anger, fear, did not act out
-The patient shame, of anger
will not act out insecurity, toward others.
anger toward loneliness,
-The patient
others. etc. Talking
about feelings spent time
-The patient can lead to with the nurse
will spend problem-solvi and focus on
time with the ng and growth one thing he
nurse and for the client. or she would
focus on one -Remain -Nurses often like to change.
thing he or she neutral but want to be
firm. seen as “nice” -The patient
would like to
However, stated that he
change.
being will continue
-The patient professional the treatment
will state that and on an
he will maintaining outpatient
continue the limits is the basis.
treatment on better
therapeutic -The patient
an outpatient
approach. talked about
basis.
feelings and
-The patient - Keep goals -It can take a perceptions
will talk about very realistic long time to and did not act
feelings and and go in small positively on them at
steps. change
perceptions least twice.
ingrained,
and not act on
life-long, -The patient
them at least maladaptive focused on
twice. habits; one problem
-The patient however, and worked
change is
will focus on through the
always
one problem problem-solvin
possible.
and work g process with
through the -Work with the -The client the nurse.
problem-solvin client on might not -The patient
g process with problem-solvin know how to
practiced the
the nurse. g skills using a articulate the
substitution of
situation that is problem.
-The patient bothering the Helping functional
will practice client. Go step identify skills for times
the by step: define alternatives of increased
substitution of the problem, gives the anxiety with
functional then explore client a sense the nurse
skills for times alternatives, of control.
of increased and make Evaluating the
anxiety with decisions. pros and cons
the nurse of the
alternatives
facilitates
choosing
potential
solutions.
 -When the Increasing
client is ready skills help the
and interested, client use
teach the client healthier ways
coping skills to to defuse
help defuse tensions and
tension and
get needs
trouble feelings
met.
(e.g., anxiety
reduction, and
assertiveness
skills).

-Give the client -Reinforcing

positive positive
attention when behaviors
behaviors are might
appropriate increase the
and likelihood of
productive. repetition.
Avoid giving Ignoring
any attention negative
(when possible behaviors
and not (when
dangerous to feasible) robs
self or others) the client of
when the even negative
client’s attention.
behaviors are
inappropriate.

3. Complete the Student Mental Health Assessment Questionnaire (a self-assessment tool).

Information gathered will be treated with the utmost confidentiality.