Component Task: Assessing a Client in the Community

This is a form of assessment done by the RCPN on a client in the community to identify risk factors and causes of mental ill health. This can be done during the nurse’s routine activities in the community or through a distress call made to the RCPN on psychiatric emergencies by client, family member/caregiver and or an opinion leader.

Aims

·         Assess clients to identify risk factors, causes of mental ill health and refer appropriately

·         Help mitigate crisis in the family and promote conducive home environment

·         Early identification of new clients for prompt management

·         Prevent injury to self and others

·         Prevent destruction of property

·         Provides a baseline data for further management

·         Reduce stigmatization

·         Inform decision on resource allocations

Requirements

·         A Well-Equipped Home Visit Bag (refer to content)

·         Community Map

·         Manual/electronic area register/ records of the client

·         Means of Transportation

Steps

1.        Read map of the community or use GhanaPost Global Positions System (GPS) address to identify the location of the centre

2.      Announce your presence, enter on response, greet and introduce yourself to client, family and significant other

3.      Establish rapport (refer to procedure) and enquire about the general health of client

4.      Explain purpose of visit

5.      Ensure privacy and confidentiality by asking the client to identify a suitable place for the assessment

6.      Ensure the environment is clean, safe and conducive for the assessment

7.       Enquire about:

·         Biographic data

·         Family history of mental illness

·         Present and past psychiatric history

·         Present and past medical history

8.      Assess client on the following:

·         Appearance/Behaviour/habits

·         Perception/orientation/insight

·         Thought/Speech

·         Mood

·         Cognition/memory/judgement

9.      Draw a care plan based on needs identified

10.    Educate client and family on prevailing health issues

11.      Refer problems beyond scope to the nearest mental health unit or health facility

12.    Inform client about your next visit

13.    Leave your contact with client and or caregiver and encourage them to call in case of emergency

14.    Document the care and findings in the report book

15.    Express appreciation and depart