Assessment is a vital aspect of nursing care. Assessment is the first phase of the nursing process. A thorough assessment involves gathering information and data about and related to the patient.
The data that is collected includes physiological, psychological, environmental, sociocultural, economical, spiritual, and developmental history of the patient. Data may be objective or subjective. Objective data refers to the measurable and observable signs, such as the patient’s heart rate, blood pressure, oxygen saturation, temperature, facial expression, gait, color, etc.Subjective data is obtained from the patient himself and it is the patient’s account of their feelings, needs, and strengths.
Data can be obtained by physical examination and by interviewing the patient, family, friends, and other health care providers (HCPs). Assessment tools help to identify areas of actual or potential problems that need further exploration. They enable HCPs to help pinpoint health issues and further assistance in the promotion of, improvement of, and maintenance of the health of the individual. “Living with a diagnosis of HIV/AIDS pervades and infuses one’s life in much the same way that race and gender do.For mothers, a diagnosis of HIV is a life-altering experience that deeply influences maternal identity, maternal role, and maternal thinking “ (de Chasney, 115).
When working with HIV infected mothers, three assessment tools that can be used are the Perceived Stress Scale, Social Support Questionnaire, and the Beck Depression Inventory. When demand is placed upon an individual that is perceived to be greater than the individual has the reserve to cope with, there is an imbalance in their ability to cope which gives rise to a negative emotional response, such as labeling oneself as being stressed.“The PSS is a 14-item scale designed to measure the degree to which individuals appraise situations in their lives as stressful. An abbreviated scale, including 4 of the original scale items, has also been developed.
PSS items were designed to tap the degree to which respondents find their lives unpredictable, uncontrollable, and overloading: three issues central to the appraisal of stress” (Cohen, 1986).The PSS is a self-administering questionnaire that explores the individual’s feelings encountered over a month period and measures the degree to which the individual considers certain situations as stressful to one’s life. The items 1-10 are general questions, and they have five responses each ranging from “never” to “very often”. In scoring the PSS, reverse the score for the responses to items numbers: 4, 5, 7, and 8 (the positively scored items), and all the scores across the 10 items are summed up.
The scores range from 0-40; the higher the score is, the greater the stress.According to Cohen (1986), “because it (PSS) does not tie appraisal to particular situations, it is sensitive to the nonoccurrence of events as well as to the ongoing life circumstances, to stress resulting from events occurring in the lives of friends and relatives, and to expectations concerning future events” (p. 718). By using the PSS is the assessment phase of the nursing process, the nurse can possibly identify the patient’s risk for stress, explore how the patient copes in a stressful situation, and design a way to work with the patient in a way that can improve the quality of care the patient receives.The SSQ is an important tool in the assessment phase of the nursing process.
It gives the HCP insight into how loved and valued the patient is, as well as how much help and support is available for the patient in the community. The SSQ prepares the HCP for the possible need to refer the individual with no social support to social services. The availability of a good support system has a tremendous impact in promoting an individual’s psychological health. Social Support Questionnaire (SSQ) is an assessment tool used to measure an individual evaluation of social support that may be available to them in case of untoward circumstances.
It was designed for both adolescents and adults. “Each item of the SSQ has two parts. The Social Support Questionnaire that grew out of the pilot work consists of 27 items. Each one asks a question to which a two-part answer is requested. The items ask that subjects (a) list the people to whom they can turn and on whom they can rely in given sets of circumstances and (b) indicate how satisfied they are with these social supports” (Sarason, Levine, & Basham, 1983).
HIV infected mothers are at risk for anxiety and depression related to the disease process, and they face immeasurable stigmatization, marginalization, and discriminations, but by having a good support system and resource group, promotion of their physical and psychological health is foreseeable. The SSQ will help in identifying those who need referrals to social services. In 1961 Aaron T. Beck, a cognitive therapist, developed The Beck Depression Inventory (BDI).
It is a survey that consists of 21 questions to be completed by the patient.It measures the strength, severity, and profundity of depression in individuals with various psychiatric diagnoses. According to Dozois, Dobson, and Ahnberg (1998) “The BDI proposes to measure the presence and severity of depression in psychiatrically diagnosed patients and in normal populations of both adolescents and adults” (p. 83). Although it is not uncommon to see the individuals self-administering the BDI, it was designed for use by trained professionals and administered in five to ten minutes.Each of the 21 questions has four possible responses; each answer is scored on a scale of 0 to 3, and this reflects the severity of the depression (Polgar, 2003).
“Individual questions of the BDI assess mood, pessimism, sense of failure, self-dissatisfaction, guilt, punishment, self-dislike, self-accusation, suicidal ideas, crying, irritability, social withdrawal, body image, work difficulties, insomnia, fatigue, appetite, weight loss, bodily preoccupation, and loss of libido”, (Polgar, 2003).Questions 1-13 deal with psychological symptoms, while the remaining questions deal with physical symptoms. The total score of 21 in the general population indicates depression. A score of 0-9 indicates minimal depression, 10-16 indicates mild depression, 17-29 indicates moderate depression, and 30-63 indicates severe in people that were already diagnosed with depression (Polgar, 2003).
The BDI has been tested for validity, reliability as well as sound psychometric properties in a primary care setting among adolescents while being used by HCPs in various healthcare settings.Using the Beck Depression Inventory in the assessment phase of the nursing process can aid in the early detection and treatment of depression, opening the possibly of managing the depression, keeping it under control, and preventing it from escalating into major depression and the complications it entails. Depression is a common thing among people living with HIV/AIDS. Depression is the cumulative effect of the enormous amount of stress that comes with being HIV positive.
Using the BDI is essential to identify and treat depression in this population.The nurse should let the patients know that depression is treatable, and help patients with referrals to the health care provider, encourage them to attend group therapy, and to take their medications as prescribed. Living with HIV/AIDS can be stressful. For mothers living with HIV/AIDS, coping with antiviral therapy, side effects and complications of the medications, making lifestyle changes, disclosure issue, social isolation, financial difficulties, and the ultimate fatality of the disease, being overwhelmed and stressed is putting it lightly.High scores indicating a high stress level among this vulnerable population can weaken an already compromised immune system and increase their vulnerability to infections and other illnesses.
The HCPs role is to encourage the patient to look for stress-reducing techniques that work best for them, such as adequate rest and exercise, meditation, deep breathing, meditation, visualization, adequate nutrition, music, or keeping a journal.
