P SY C H OS O C I A L

E D B Y: D A RYL AB RA HAM
PREPAR
DEFINITION

A PSYCHOSOCIAL ASSESSMENT IS AN EVALUATION OF AN INDIVIDUAL'S MENTAL

HEALTH AND SOCIAL WELL-BEING. IT ASSESSES SELF-PERCEPTION AND THE
INDIVIDUAL'S ABILITY TO FUNCTION IN THE COMMUNITY. THE PSYCHOSOCIAL
ASSESSMENT GOAL IS TO UNDERSTAND THE PATIENT TO PROVIDE THE BEST CARE
POSSIBLE AND HELP THE INDIVIDUAL OBTAIN OPTIMAL HEALTH.
DEFINITION

• THE PSYCHOSOCIAL ASSESSMENT HELPS THE NURSE DETERMINE IF THE PATIENT

IS IN MENTAL HEALTH OR A MENTAL ILLNESS STATE. MENTAL HEALTH IS A STATE
OF WELL-BEING WHERE THERE IS THE ABILITY TO DEAL WITH THE TYPICAL
STRESSES OF LIFE, WORKS PRODUCTIVELY, AND CONTRIBUTE TO THEIR
COMMUNITY.
DEFINITION

• MENTAL ILLNESS IS A PATTERN OF BEHAVIORS THAT IS TROUBLING TO THE

PERSON OR THE COMMUNITY WHERE THE INDIVIDUAL LIVES. MENTAL ILLNESS
MAY MODIFY REALITY, INFLUENCE DAILY LIVING, OR HARM JUDGMENT.
MENTALLY ILL INDIVIDUALS OFTEN HAVE A REDUCED ABILITY TO COPE WITH
SOCIETY, MALADAPTIVE BEHAVIORS, AND A REDUCED ABILITY TO FUNCTION.
CONDUCTING A PSYCHOSOCIAL ASSESSMENT

• MEDICAL EXPERTS CONDUCT THIS EVALUATION TO SHED LIGHT ON SOME

SOCIAL OR PSYCHOLOGICAL FACTOR THAT MAY BE AFFECTING A PERSON’S
HEALTH, BE IT PHYSICAL OR MENTAL. HENCE, IT IS VERY IMPORTANT THAT THIS
EXAMINATION BE CONDUCTED IN A WAY THAT PUTS THE PATIENT AT EASE WITH
THE EXAMINER.
• THE ONE WHO IS CONDUCTING THE EVALUATION ESTABLISHES A FRIENDLY RAPPORT WITH THE
PATIENT SO THAT THE PATIENT FEELS LIKE OPENING UP TO THE EXAMINER.

• THE PHYSICAL OR MENTAL PROBLEM(S) FACED BY THE PATIENT ARE CAREFULLY STUDIED SO
THAT THE EXAMINER HAS A COMPLETE IDEA OF THE CAUSES, SYMPTOMS, AND IMPACT OF THAT
PROBLEM.

• THE PATIENT’S STRENGTHS AND WEAKNESSES ARE ALL TAKEN INTO CONSIDERATION, ALONG
WITH HIS PERSONALITY, HIS LIKES AND DISLIKES, HIS TEMPERAMENT, ETC.
• THE EVALUATOR ALSO TRIES TO GAIN MAXIMUM INFORMATION ABOUT ANY RECENT SOCIAL
INCIDENTS OR PSYCHOLOGICAL FACTORS THAT MAY HAVE AFFECTED THE PATIENT
SIGNIFICANTLY.

• THE ASSESSMENT ALSO TAKES INTO CONSIDERATION THE PATIENT’S CURRENT AND PREVIOUS
LIFESTYLE, ALONG WITH HIS DIET, ADDICTIONS (IF ANY) AND RELATIONSHIPS.

• THIS INFORMATION IS THEN CROSS-CHECKED WITH FRIENDS AND RELATIVES OF THE PATIENT TO
ASSURE THAT THE ANSWERS GIVEN IN THE EXAMINATION ARE CORRECT.
• THE ASSESSMENT FORMED AFTER THE CROSS-CHECKING IS THEN WRITTEN IN A DETAILED
FORMAT, WHICH WILL BE USED TO PROVIDE INFORMATION ABOUT A PATIENT TO ANY EXPERT
WHO MIGHT REQUIRE IT, NOT NECESSARILY ONLY THE EXAMINER.

• THE ASSESSMENT IS EXPECTED TO BE A DETAILED REPORT OF THE PATIENT’S MEDICAL HISTORY,

PSYCHOLOGICAL HISTORY, REASON FOR REQUIRED TREATMENT, INFORMATION ABOUT
PATIENT’S PREVIOUS MEDICATIONS, ALLERGIES, ANY LEGAL ISSUES, SOCIAL FUNCTIONING OF
THE PATIENT, HISTORY OF SUBSTANCE ABUSE (IF APPLICABLE), HISTORY OF VIOLENCE OR
VICTIMIZATION, SUICIDAL TENDENCIES, ETC.
PSYCHOSOSIAL ASSESSMET
THE MAJOR COMPONENTS OF A PSYCHOSOCIAL INTERVIEW INCLUDE:

• IDENTIFYING THE PATIENT

• CHIEF COMPLAINT
• HISTORY OF PRESENTING ILLNESS
• PSYCHIATRIC HISTORY
• MEDICAL OR SURGICAL HISTORY
• MEDICATION LIST
• ALCOHOL AND DRUG USE
• CULTURAL ASSESSMENT
• FINANCIAL ASSESSMENT
• COPING SKILLS
• VIOLENCE RISK ASSESSMENT
• FAMILY OR SOCIAL HISTORY
• OCCUPATIONAL HISTORY
• EDUCATIONAL HISTORY
• LEGAL HISTORY
• DEVELOPMENTAL HISTORY
• SPIRITUAL ASSESSMENT
• INTERESTS
• ABILITIES
• MENTAL STATUS EXAMINATION
PSYCHOLOGICAL ASSESSMENT
• THE FIRST STEP IN ANY ASSESSMENT IS TO IDENTIFY THE PATIENT. A PATIENT'S IDENTITY
INCLUDES THE PATIENT'S NAME, GENDER, BIRTH DATE OR AGE, MARITAL STATUS, RACE,
ETHNICITY, AND LANGUAGES SPOKEN.

• THE CHIEF COMPLAINT IS THE MAIN REASON THE PATIENT IS PRESENTING, IN THEIR OWN
WORDS. THE HISTORY OF THE PRESENT ILLNESS IS THE CHRONOLOGICAL ACCOUNT OF WHAT
LED UP TO THE CHIEF COMPLAINT. THIS SECTION MAY INCLUDE THE PROBLEM'S LOCATION,
DURATION, SEVERITY, TIMING, CONTEXT, MODIFYING FACTORS, AND ASSOCIATED SIGNS OR
SYMPTOMS.
PSYCHOLOGICAL ASSESSMENT
• THE PSYCHIATRIC, PSYCHOLOGICAL HISTORY IS THE HISTORY OF ALL PSYCHIATRIC OR
PSYCHOLOGICAL CONCERNS IN THE PAST. THE MEDICAL OR SURGICAL HISTORY INCLUDES
LISTING ALL MEDICAL ILLNESSES AND LISTING ALL SURGERIES AND DATES. ALL CURRENT AND
PAST MEDICATIONS SHOULD BE LISTED, INCLUDING THE DOSE AND FREQUENCY. FOR
MEDICATIONS CURRENTLY TAKEN, A LISTING OF WHO PRESCRIBED THEM AND WHY THEY ARE
PRESCRIBED SHOULD BE DOCUMENTED. FOR PAST PRESCRIBED MEDICATIONS, A LISTING OF
WHY THEY WERE STARTED AND WHY THEY WERE STOPPED SHOULD BE DOCUMENTED.
PSYCHOLOGICAL ASSESSMENT
• HISTORY OF ALCOHOL AND DRUG USE IS AN IMPORTANT PART OF THE PSYCHOSOCIAL
ASSESSMENT. THE SUBSTANCES CURRENTLY USED SHOULD BE DOCUMENTED, INCLUDING THE
METHOD OF USE (ORAL, INHALATION, INJECTION, INTRANASAL), THE AMOUNT, THE
FREQUENCY, AND THE TIME. ANY SUBSTANCES USED IN THE PAST SHOULD BE DOCUMENTED.
COMMON ABUSE SUBSTANCES INCLUDE ALCOHOL, HEROIN, OPIATES, MARIJUANA, COCAINE,
CRACK, METHAMPHETAMINES, INHALANTS, STIMULANTS, HALLUCINOGENS, CAFFEINE, AND
NICOTINE.
PSYCHOLOGICAL ASSESSMENT
• VIOLENCE RISK INCLUDES AN ASSESSMENT OF SUICIDAL IDEATION, HOMICIDAL RISK, AND ABUSE.
WHILE IT IS DIFFICULT TO PREDICT WHO WILL COMMIT SUICIDE, RISK FACTORS FOR SUICIDE INCLUDE
A PREVIOUS SUICIDE ATTEMPT, FAMILY HISTORY, FEELINGS OF HOPELESSNESS, DRUG AND ALCOHOL
ABUSE, HISTORY OF DEPRESSION OR BIPOLAR DISORDER, FEELING ISOLATED, PHYSICAL ILLNESS,
HISTORY OF AGGRESSIVENESS OR IMPULSIVITY, UNWILLINGNESS TO SEEK HELP OR BARRIERS TO
MENTAL HEALTH TREATMENT.1

• RISK FACTORS FOR HOMICIDAL BEHAVIOR INCLUDE MALE GENDER, GANG AFFILIATIONS,
UNEMPLOYMENT STATUS, DRUG OR ALCOHOL USE, ACTIVE PSYCHOTIC SYMPTOMS, AND LOWER
SOCIOECONOMIC STATUS.
QUESTIONS TO ASK TO ASSESS VIOLENCE RISK

• HAVE YOU HAD THOUGHTS OF HURTING YOURSELF?

• HAS THERE BEEN A PREVIOUS SUICIDE ATTEMPT? WHEN?
• DO YOU HAVE A PLAN TO COMMIT SUICIDE?
• IS THERE A MEANS TO CARRY OUT THE PLAN?
• IS THERE INTENT TO CARRY OUT THE PLAN?
• HOW LETHAL IS THE PLAN?
• DO YOU HAVE THOUGHTS OF HARMING OTHERS? IF YES, WHO IS THE TARGET?
• CAN THESE THOUGHTS OF HARM BE MANAGED?
• DO YOU HAVE THE MEANS TO CARRY OUT A PLAN TO HARM OTHERS?
• IS THERE INTENT TO CARRY OUT THE PLAN?
• WHAT IS THE LETHALITY OF THE PLAN?
• DO YOU HAVE ANY HIGH-RISK BEHAVIORS SUCH AS SELF-CUTTING, ANOREXIA, BULIMIA, HEAD
BANGING, OR OTHER SELF-INJURIOUS BEHAVIORS?
ABUSE ASSESSMENT

• IN THE PAST YEAR, HAVE YOU BEEN HIT, KICKED, OR PHYSICALLY HURT BY ANOTHER PERSON?
• ARE YOU IN A RELATIONSHIP WITH SOMEONE WHO THREATENS OR PHYSICALLY HARMS YOU?
• HAVE YOU EVER BEEN FORCED TO HAVE SEXUAL CONTACT THAT YOU WERE NOT COMFORTABLE
WITH?

• HAVE YOU EVER BEEN ABUSED? IF YES, DESCRIBE BY WHOM, WHEN, AND HOW.
SKILLS REQUIRED FOR PSYCHOSOCIAL ASSESSMENT

ASIDE FROM BEING KNOWLEDGEABLE ABOUT THE APPROACH OF PSYCHOSOCIAL ASSESSMENT,

THERE ARE A FEW OTHER SKILLS WHICH ARE REQUIRED TO BE PRESENT IN THE EXAMINER.

• EXCELLENT COMMUNICATION SKILLS

• ABILITY TO POSE QUESTIONS WITH TACT
• SYMPATHETIC NATURE
• ABILITY TO BOND WITH THE PATIENT
THANK YOU!