PSYCHOSOCIAL ASSESSMENT

I. History - pertinent data of the client such as age, developmental stage, social, cultural and spiritual beliefs. This provides some insight of client’s past and current situation.

II. General Appearance and Motor Behavior
- overall appearance including dress, hygiene and grooming. Motor behavior includes automatisms’ psychomotor retardation and waxy flexibility.

III. Mood and Affect
- mood and affect are different. Mood refers to client’s pervasive and enduring emotional state. Affect means the outward expression of the client’s emotional state. We have blunted affect, broad affect, flat affect, inappropriate affect and restricted affect.

IV. Thought Process and Content
- it is refers to how the client thinks and what the client says. The nurse must assess for the circumstantial thinking, delusions, flight of ideas, tangential thinking, word salad, thought withdrawal, thought insertion, thought blocking, thought broadcasting, ideas of reference, and loose associations.

V. Sensorium and Intellectual Processes
- the nurse must assess for the orientation, memory and ability to concentrate of the client.
- Patient’s ability to think must be included in the assessment, and how the client makes associations and interpretations of a given situation.

VI. Judgement and Insight
- Judgement is the ability to interpret one’s environment and situation correctly and adapts one’s behavior and decisions accordingly. Insight is the ability to understand the true nature of one’s situation and accept some personal responsibility for that situation.

VII. Sensory-Perceptual Alterations
- assess if the client is experiencing some hallucinations.

VIII. Self-Concept
- it is the way on how one view oneself in terms of personal worth, value and dignity.

IX. Roles and Relationship
- assess the client’s functional ability to fulfill or perform his or her role and responsibility.

X. Physiologic and Self-care Concerns
-assessment includes client’s physiological functioning and how he or she take care of themselves.

The purpose of Psychosocial Assessment is to construct a baseline clinical picture of the client’s current emotional state, mental capacity and behavioral function as basis for developing a plan of care to meet the specific client’s need. In assessing the client, the nurse must know how to do it properly to gain all the essential informations needed to help the client. Proper assessment and therapeutic use of self and therapeutic communication is a big factor to make your assessment accurate and complete. Examining one’s own beliefs and gaining self-awareness is a growth-producing experience for the nurse.