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NUR 282 MENTAL HEALTH NURSING

PSYCHOSOCIAL ASSESSMENT TOOL

Date: _____10/11/10______________

Client initials: Age: ______62_________ Gender: _____F__________

____NH___________
Allergies: ___________Penicillan, Amoxicillin__________________________________________

Admission date:
________06/23/2008________________________________________________________________

Admission status___Full Time Disabled______________________________________________

Advance directive signed:

________N/A________________________________________________________

Diagnoses: Axis I: __Schizophrenia_______________________________________

Axis II: ____________________________Not Known_____________________
Axis III: _________________NK_______________________________________
Axis IV: __________________NK________________________________
Axis V: _______________NK_________________________________________________

Reason for admission:

______________________Schizophrenia_____________________________________________

Client’s perception: _Feels mistreated by current nursing staff, shows signs of using blame as a
defensive mechanism. Overall understands why treatment is being
received._____________________________________________________

Perception of others: __Views many others as out to get her, negative towards staff and some other
residents. Feels mistreated by staff, and complaints do seem slightly
valid.__________________________________________________________________

Precipitating factors: __________________Stress, Inability to cope, Respiratory

infection__________________________________________________

Predisposing (risk) factors (family history): ___None

Known_______________________________________________

Treatment history: ____Institutionalized since 2002 in various hospitals and care

settings__________________________________________________________________

Present medications (including supplements, vitamins, herbal preparations): _Not Known at this
time_______________________
____________________________________________________________________________________
_

Substance use or dependence: __Smoking, Alcohol use, Hxt of Marijuana

use___________________________________________________________

Primary language:
___________English___________________________________________________________
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Living situation: _____________Permanently disabled resident of the

state__________________________________________________________

Ethnicity/culture: ________Caucasian / European

_______________________________________________________________

Cultural and spiritual beliefs and practices: _________Non-practicing

Catholic__________________________________________

Health beliefs and practices: ________Western Medicine, High feeling of standards of care needed,
Feels care level currently inadequate______________________________________________________

Educational and work history (include volunteer work, income): ___Some High School 10th grade,
Worked as a maid, but no steady employment_______________________________

Mental status: _______Alert to Person, Place, and Environment. Was able to name day/week/month,
president, recalled my name and others well, Knew where she was and basic time
schedules___________________________________________________________________

General appearance (dress, behavior, posture, eye contact): _Proper dress, Lethargic behavior, Sloped
posture, Minimal Eye contact, Slow speech_____________________________________

Motor behavior: ____Slow movements, weak bilaterally in arms and legs, Responsive to sensation and
desired movement____________________________________________________________________

Speech: ___Soft, Slow, Slight slurring of

words____________________________________________________________________________

Mood and affect: _Downcast and tired, Flat

affect______________________________________________________________________

Thought process (how the client thinks, including cognition): _Client flows from one subject to another
more freely then normal, but overall is mostly coherent. Focuses on various illnesses almost to the point
of being a hypochondriac. Intensely focuses on one item for brief periods, and then focus shifts.
___________________________________
____________________________________________________________________________________
Thought content (what the client thinks about, including delusions): _No real delusions presenting, at
one point asked if her son was there but quickly reoriemtated herself. Preoccupied manly focusing on her
treatment and illness.______________________________
___________________________________________________________________________________

Sensorium and intellectual processes (orientation, memory, concentration, attention, intellectual

functioning, hallucinations): _Short and Long-term memory tested, and seems to be correct. Client tends
to make up stories about her past. Client unable to completely concentrate for even short periods on
tasks. Attention span short, but client is cooperative. Client functions intellectually around a fourth grade
level. No hallucinations presented on
shift._____________________________________________________________
____________________________________________________________________________________
Suicidal or homicidal ideation:
____________________________________________________________
No, thoughts/plans reported, shows no signs of ideation
Judgment and insight: _Judgment seems poor in relating to self-care and time management. Client seems
not too insightful and needs explanation for common
functions.__________________________________________________________________
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Self-concept: _Views self as constantly ill, remains negative based on views of wellness, and care
received._________________________________________________________________________

Roles and relationships: _Client is ward of state, but has family most out of town but daughter visits
occasionally. Able to build social relationships with other residents, but remains mostly withdrawn
especially towards
staff._________________________________________________________________

Physiologic and self-care concerns (medical problems, physical impairments or disabilities, self-care
deficits, review of systems): Client seems more preoccupied with sadness then completing ADLs and
Views her illness and the treatment of her illness as improper care being received. Client has generalized
weakness but can complete ADLs if thoroughly
motivated_____________________________________________________________
____________________________________________________________________________________
Client strengths: _Cooperation with treatment, Strong memory skills,
_______________________________________________________________________

Coping skills and defense mechanisms (effective and ineffective): _Fluctuations in attitude, smoking,
health focusing, focusing on problems, blaming others(projecting)_______________________________

Interests and hobbies: __Bingo, Group activities, Meal time, Candy, Coloring, Smoking, Going outside
to see the cats__________________________________________________________________

How the client spends a typical day: _Follows smoking schedule, Activities, Minimal socializing outside
activities, Go outside to visit cats, Complies fairly well with facility
schedule.____________________________________________________

Teaching needs: _Smoking Cessation, Health Maintenance, Diversional activities, Relaxation

techniques_______________________________________________________________________

Barriers to learning: _Attention span, Attitude, Fatigue, Mental

capacity____________________________________________________________________

Client’s expectations for care: _Very high standards for fair and proper care. Client currently feels
standards are not being met.____________________________________________________________

Discharge planning: __No, discharge plan at this

time___________________________________________________________________

Signature:
____________________________________________________________________________