Psychosocial Assessment Flashcards
Basic interview:
Stages
1. OPENING/INTRODUCTION • SETS THE TONE 2. BODY/DEVELOPMENT • PATIENT RESPONDS TO QUESTIONS 3. CLOSING • TERMINATION OF THE INTERVIEW
Basic interview:
Opening/Introduction
• ESTABLISH RAPPORT
• EXPLAIN PURPOSE AND NATURE OF INTERVIEW
• “MAY I SIT DOWN FOR ABOUT 10 MINUTES TO
TALK ABOUT WHAT BROUGHT YOU INTO THE HOSPITAL?”
• “ FEEL FREE TO SAY IF THERE IS ANYTHING YOU DON’T WANT TO TALK ABOUT.”
Basic Interview:
Body/Development
Types of interview questions
• CLOSED: ANSWER IS RESTRICTED TO FEW WORDS • OPEN-ENDED: INVITATION TO EXPLORE THOUGHTS/FEELINGS • NEUTRAL: FREEDOM TO ANSWER WITHOUT PRESSURE • LEADING: LIMITS ACCURACY OF RESPONSE
Basic Interview:
Body/Development
- LISTEN ATTENTIVELY
- USE SIMPLY LANGUAGE
- CLARIFY POINTS NOT UNDERSTOOD
- QUESTION IN LOGICAL SEQUENCE
- ASK ONE QUESTION AT A TIME
- DO NOT IMPOSE OWN VALUES
- AVOID USING PERSONAL EXAMPLES
- CONVEY RESPECT AND INTEREST
- BE AWARE OF BODY LANGUAGE
- BE AWARE OF VOICE
- SIT AT EVEN LEVEL
- USE SILENCE TO ALLOW PATIENT TO ORGANIZE THOUGHTS
- USE EYE CONTACT AND BE UNHURRIED
Basic Interview:
Closing
- OFFER TO ANSWER QUESTIONS
- OFFER CLEAR CONCLUSION
- THANK THE PATIENT
- EXPRESS CONCERN FOR FUTURE WELFARE
- PLAN FOR NEXT MEETING
- PROVIDE A SUMMARY
Considerations to take when doing a psychosocial assessment
- EFFECTIVE NURSE COMMUNICATION • HOLISTIC APPROACH
- INTERVIEW ENVIRONMENT
- PATIENT’S DEVELOPMENTAL LEVEL
- PATIENT EMOTIONAL FACTORS • PATIENT FAMILY FACTORS
- PATIENT CULTURE
Psychosocial assessment goal:
To understand patient
Psychosocial assessment evaluates:
- MENTAL HEALTH & ILLNESS
- SOCIAL WELL-BEING
- PERCEPTION OF SELF
- ABILITY TO FUNCTION IN COMMUNITY
- MULTIPLE DOMAINS OF MENTAL STATUS
Components of psychosocial assessment
- IDENTIFY PATIENT
- CHIEF COMPLAINT
- HISTORY OF PRESENT ILLNESS
- PSYCHIATRIC HISTORY
- MED/SURG HISTORY
- MEDICATION LIST
- ALCOHOL & DRUG USE
- FAMILY HISTORY
- DEVELOPMENTAL HISTORY
- SOCIAL HISTORY
- VIOLENCE RISK
- MENTAL STATUS EXAM
Social hx components
- SOCIAL RELATIONSHIPS
- LIVING SITUATION
- SIGNIFICANT LIFE EVENTS
- EMPLOYMENT
- EDUCATION
- LEGAL
- SPIRITUAL
- CULTURAL
- FINANCIAL SITUATION
- COPING SKILLS
- INTERESTS/HOBBIES
How to obtain military hx?
GENERAL QUESTION
• “WOULD IT BE OKAY IF I ASKED ABOUT YOUR MILITARY EXPERIENCE?”
IF ANSWERS IN AFFIRMATIVE:
• “HOW HAS MILITARY SERVICE AFFECTED YOU?
• “DID YOU SEE COMBAT, ENEMY FIRE, OR CAUSALITIES?”
• “WERE YOU OR A BUDDY WOUNDED, INJURED, OR
HOSPITALIZED?”
• “DO YOU HAVE A SERVICE-CONNECTED CONDITION?”
Questions to ask for:
self-harm
- Have you had thoughts of hurting yourself?
- Do you ever cut or injure/harm yourself?
Questions to ask for:
Suicide risk
- Have you had thoughts of hurting yourself?
- Can these thoughts of harm be managed?
- Do you have a plan to commit suicide? What is the plan?
- Do you intend to carry out the plan?
Questions to ask for:
Homicide risk
- Do you have thoughts of harming others?
- Who is the target?
- Is there intent to carry out the plan?
- Do you have a means to carry out a plan to harm others?
Questions to ask for:
Abuse
• Are you in a relationship with someone who physically harms or threatens you?
