Nursing & Healthcare International Journal

MEDWIN PUBLISHERS ISSN: 2575-9981

Committed to Create Value for Researchers

Mental Health Nursing Evaluation Form: A Patient Assessment

Guide

Salgado RH* Short Communication
Volume 5 Issue 1
Faculty of Health Sciences, University of Talca, Chile
Received Date: January 23, 2021
 
Published Date: February 10, 2021
*Corresponding author: Raúl Hormazábal-Salgado, School of nursing, Faculty of Health
DOI: 10.23880/nhij-16000233
Sciences, the University of Talca, Avenida Lircay s/n, Talca, Chile, Email: [email protected]

Abstract

Nursing notes are essential for mental health nursing, and thus they should be included in mental health education for
undergraduate nursing students. In clinical settings, It has been observed that fourth-year nursing students commonly
omitted critical information from the assessment of mentally ill patients, neglecting their requirements as well as losing
valuable learning opportunities. For this reason, an evaluation form has been created and implemented in order to optimise
the student’s learning opportunities.
The main objectives that motivated the design of this instrument were to support the nursing student’s learning process,
promote a systematic record of the mental examination, and apply specific descriptors in the assessment of the patient’s
mental state.
This evaluation form was designed according to a systematic and standardized registration system, including the main areas
that compose mental health assessment.
This cost-effective tool has significantly facilitated the student’s learning and training in mental health nursing. During the
five-year period in which this instrument has been applied, student records improved in quality, precision, as well as a positive
opinion about it from students. Besides, this document has been recently used in the context of distance education and clinical
simulation in mental health by assessing patients in simulated situations, with positive outcomes.

Keywords: Assessment; Mental health nursing; Education; Health Education; Nurse’s note

Mental Health Nursing Evaluation Form: A The mental health nursing evaluation form is basically a
Patient Assessment Guide structured assessment sheet where the students can develop
their own nursing notes. This innovation has been initiated
Nursing notes are used primarily as a communication as a teaching instrument in the context of the systematization
tool between nurses, doctors and member of the professional of the record of the mental examination assessment in 2015,
team to ensure continuity of patient care. The use of nursing with fourth-year nursing students at the University of Talca.
progress notes of the Psychiatric Department allows, among
other things, a better understanding of the life course of some At first, before implementing this innovation, it
hospitalized patients [1]. Therefore, these notes are essential was observed that students commonly omitted critical
for nursing education, and must be incorporated during the information from the assessment of mentally ill patients,
training process for undergraduate nursing students. neglecting their requirements as well as losing valuable

Mental Health Nursing Evaluation Form: A Patient Assessment Guide Nurs Health Care Int J
 2 Nursing & Healthcare International Journal

learning opportunities. This was a serious problem due to nursing student’s learning process, promote a systematic
the limited seven-day period spent per student on these record of the mental examination, and apply specific
clinical settings. descriptors, so-called technical concepts, in the assessment
of the patient’s mental state.
An evaluation form was created and implemented in order
to optimise the student’s learning opportunities in the clinical This evaluation form was designed according to a
field. These assessment instruments help development of systematic and standardized registration system. The
care plans by identifying client needs, utilization of social assessment sheet covers most areas one would expect when
resources, and evaluation of outcomes [2]. Besides, it is assessing the needs of clients with mental health disorders,
possible to improve nurse skills in documentation of care and for developing a care plan. These areas are based on the
by means of clear assessment instruments, resulting in high book titled “Psychiatric Semiology” from Caponi [4]. Students
quality nursing care [3]. must select the options that best represent the patient’s
behaviour, mental and emotional state, among other relevant
The main objectives that motivated the design of the areas (Table 1).
mental health nursing evaluation form were to support the

Area Main items

General description Appearance and hygiene, habits, sleep pattern, support network
Rapport with the examiner, psychomotor activity and behaviour, attitude towards the examiner,
Behavioural description
mechanisms for coping with stress
Verbal communication, tone of voice, verbal response, understand ability of language, reliability
Language
of the story
Humour and affectivity Mood, predominant emotion, alteration of affect, level of self-esteem
Psychotic symptoms (e.g. hallucinations, delusions) Disorders not associated with psychosis (e.g.
Perception disturbances
hearing loss, visual difficulty) Content, structure and speed of thought
Thought processes Content, structure and speed of thought
Sensory and cognition State of consciousness, orientation, memory and impulse control
Judgment and reasoning Degree of understanding of the consequences of their actions, awareness of mental illness
Table 1: Main items per area, assessed by the evaluation form.

Between 2015 and 2020, this document has been been applied, student records improved in quality, precision,
progressively modified in conjunction with the students and a positive opinion about it from students. Besides,
who have utilised it. This has been done in order to facilitate this document has been recently used in the context of
the assessment of the mental state of the people assisted, distance education and clinical simulation in mental health
in addition to encouraging the active participation and by assessing patients in simulated situations, with positive
empowerment of students in the development and evaluation outcomes.
of an assessment sheet.
The greatest difficulty is the student’s initial lack of
After using this instrument, the students suggested familiarity with this instrument. This problem has been
modifications that were analysed together and, eventually, tacked by means of a detailed explanation from the nurse
incorporated into the form. Another relevant aspect is that tutor before using it with patients, while responding to any
the records written by the students are archived in the question, opening discussions and analysing the instrument.
clinical file of the patients treated. This allows continuity of
care, strengthening student learning in matters not only of References
assessment but also of monitoring changes in the behaviour
and mental state of the people attended, consolidating the 1. Harrisson S (2016) Nursing Progress Notes in Psychiatry:
learning. Mental Health Archival Data. Sante Ment Que 41(2): 69-
82.
This cost-effective tool has significantly facilitated the
student’s learning and training in mental health nursing. 2. Setsu S, Emiko U, Tomoko K, Akiko S, Michiko S (2001)
During the five-year period in which this instrument has Development of an assessment sheet for home care. Int J

Salgado RH. Mental Health Nursing Evaluation Form: A Patient Assessment Guide. Nurs Health Care Copyright© Salgado RH.
Int J 2021, 5(1): 000233.
 3 Nursing & Healthcare International Journal

Nurs Pract 7(3): 140-145. Int J Nurs Knowl 24(2): 108-112.

3. Odutayo P, Olaogun A, Oluwatosin A, Ogunfowokan 4. Capponi R (1987) Psychopathology and Psychiatric

A (2013) Impact of an Educational Program on the Semiology 1st(edn), Editorial Universitaria, Santiago,
Use of Standardized Nursing Languages for Nursing Chile.
Documentation Among Public Health Nurses in Nigeria.

Salgado RH. Mental Health Nursing Evaluation Form: A Patient Assessment Guide. Nurs Health Care Copyright© Salgado RH.
Int J 2021, 5(1): 000233.