Psychiatric

Psychiatric nursing assessment is a comprehensive biopsychosocial evaluation that integrates mental status examination, risk assessment, and therapeutic communication to develop a holistic understanding of the patient's mental health status. The assessment begins with establishing therapeutic rapport through active listening, empathy, and a non-judgmental stance, which is essential for obtaining accurate information about sensitive topics including suicidal ideation, substance use, trauma history, and psychotic symptoms. Risk assessment is the highest priority: suicide risk evaluation includes direct questioning about suicidal ideation (passive vs. active), intent, plan specificity, access to means, previous attempts, protective factors, and current psychosocial stressors, using validated tools such as the Columbia Suicide Severity Rating Scale (C-SSRS). Violence risk assessment evaluates history of violence, current homicidal ideation, command auditory hallucinations, substance intoxication, and acute psychotic symptoms. The nurse documents the psychiatric assessment using objective, descriptive terminology, distinguishes between patient statements (documented in quotation marks) and clinical observations, assigns appropriate safety precautions (1:1 observation, 15-minute checks, sharps restriction, elopement precautions), implements least restrictive interventions, and communicates risk assessment findings during every handoff.