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Nadia Khadra PT: R.A

PSYCHOSOCIAL ASSESSMENT
SELF CONCEPT MODE

PHYSICAL SELF
Body sensations / Subjective data
Verbal response

pt. states “ I feel a little pain in my stomach and I feel a little warm.

Body image / Subjective data pt. states, “ I don’t exercise but I should make time” I

PERSONAL SELF - (Subjective data) Pt states, “ I’m not feeling happy theses
days like before, things are not going well”. Pt looks down as she speaks. I

PERSONAL SELF - (Objective data) Pt asked lots of questions about our nursing program and expressed interest in
possibly becoming a nurse. Initially she was hesitant to speak about her new diagnose of HIV and seemed happy
discussing nursing. A

Self ideal / Verbal response

Pt states, “ I have always been the one taking care of everyone and now it looks like I will need help.” A

Moral-ethical self / Verbal response

Pt states, “I am a Lutheran by faith but I have all sorts of friends with different faiths that have been open to and
believe that God comes in many forms and words.” A
 INTERDEPENDENCE MODE

Subjective data / Verbal responses Patient's contributive (giving) behaviors

Pt states, “ I won the Martin Luther King award in 2004 for helping under privileged women. It was an extremely
rewarding and fulfilling part of my life.” A

Objective data / Non-verbal responses

Patient's contributive (giving) behaviors

Pt smiles when discussing her past achievements. A

Subjective data / Verbal responses

Patient's recipient (receiving) behaviors

Pt states, “ I love it when the whole family comes over. I know they end up making a big mess, but I love them.”
A

Objective data / Non-verbal responses

Patient's recipient (receiving) behaviors

Pt has flowers and candy in her room. She received several phone calls from at least three family members wishing
her well and planning on a visit to see her. Her step father visited her that day. A
 ROLE MODE

Primary Role:

Secondary Roles(s): Mother, Sister, Aunt

Tertiary Role (s): Hospital patient

List developmental tasks appropriate for this level of G & Describe behaviors client demonstrates which indicate
D he/she is or is not accomplishing tasks.

1. Adjusting to decreased physical strength and health Pt does not appear to be maintaining a healthy diet as she
states, “I don’t usually eat healthy foods. I love fast food.”

2. With pt recently getting sick often, she left her job and
2. Coping with new chronic illness and financial problems. stopped paying her credit card bills. She moved in with her
sister’s family. She will look into SSI benefits, food stamps
and housing.

3. Reminiscence is used to help integrate all stages of life 3.She spoke briefly of being adopted at the age of 4 by her
that is meaningful. step father and even told me she did meet he real dad once
but she is glad that he did not raise her.
A. Subjective (expressive) behaviors
Pt states, “ It will be hard to have people taking care of me when all I want is to take care of them” A

B. Objective (instrumental) behaviors

Pt still able to do daily hygiene herself, she needs assistance with ambulation for long periods because of her recent
sickness. She is still able to do mostly everything without assistance. Pt knows that there will be a day when she will
need excessive assistance. A

HEALTH MANAGEMENT ROLE: Use METHOD to assess Health Management Role.

M: Medication, E: Environment, T: Treatment,

H: Health Teaching, O: Outpatient referral and D: Diet.

M: Pt states, “I am not sure about all of those pills, they make me feel sick.” I

E: “ I must live with my sister these day. I don’t like to be dependant on anyone but I love being around my family
very much.” A

T: “ I want to know all the bad things that will happen with me in the future but at times I don’t want to know
anything, I just want to forget” I

H: “I still have many unanswered question. I know this is a complicated disease.” A

O: “ I need to speak with my case manager and get things in order”

D: Pt likes fast foods and unhealthy foods. Pt ate only half of her meal. I