MARIANO MARCOS STATE UNIVERSITY

College of Health Sciences

PSYCHOSOCIAL ASSESSMENT GUIDE

A. History

1. Age: _____

2. Developmental stage: ________________________________

Assessment focus questions:

 What are the developmental tasks expected of the client?

 Is the client’s age and developmental level congruent with expected norms?
 Is the client’s age and developmental level incongruent with expected norms because of
developmental delay or intellectual disability?

Interview focus:

 Ask the client about his or her achievement of the developmental tasks.

3. Client’s history:

Interview questions:

 Have you experienced similar difficulties in the past?

 Have you been admitted to the hospital, and if so, what was that experience like?
 Are there members of your family who had been diagnosed with alcoholism, bipolar
disorder, suicide, or other conditions? (Ask follow-up questions as necessary.)

4. Cultural and spiritual beliefs

Interview questions:

 What are your beliefs and values about your role in society?
 What are your beliefs about acceptable social or personal behavior?
 What is your perception of having eye contact during conversations or interactions?
 What are your spiritual beliefs related to mental health and illness?

5. Beliefs and practices about mental health and illness:

Interview questions:

 What are your beliefs on how to handle emotional and mental problems?

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 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

 What are your beliefs regarding the family’s role in handling emotional or mental
problems?
 What is your view about seeking outside or professional help to manage emotional and
mental problems?
 What forms of management (e.g., medication) do you believe can solve your emotional
and mental problems?
 When should you take medications? Should you only take medications when feeling sick?

B. General Appearance and Motor Behavior

Assessment focus questions:

Does the client appear to be his or her stated age?

1. Hygiene and grooming:

 Is the client unkempt or disheveled?

 Does the client appear neat and properly groomed?

2. Appropriateness of dressing:

 Is the client appropriately dressed for his or her age and the weather and situation?

3. Posture:

 How does the client appear as to posture?

4. Eye contact and facial expressions:

 Does the client maintain eye contact?

 Does the client show congruence of facial expressions with speech content?

5. Unusual movements or mannerisms:

 Does the client exhibit unusual movements or mannerisms?

As to motor behavior, does the client exhibit automatisms, psychomotor retardation,

or waxy flexibility?

6. Speech:

 Does the client talk nonstop?

#16S Quiling Sur, City of Batac, Ilocos Norte

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 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

 Does the client perseverate (seem to be stuck on one topic and unable to move to
another idea)?
 Are responses a minimal “yes” or “no” without elaboration?
 Is the content of the client’s speech relevant to the question being asked?
 Is the rate of speech fast or slow? Is the tone audible or loud?
 Does the client speak in a rhyming manner?
 Does the client use neologisms (invented words that have meaning only for the client)?
 Does the client have any speech difficulties such as stuttering or lisping?

C. Mood and Affect

Assessment focus questions:

1. Expressed emotions

 What affect/emotions do the client show?

 As to range, does the client have full range, or restricted affect?
 As to intensity, does the client have increased, flat, or blunted affect? Ask the client,
“On a scale of 1 to 10, with 1 being least depressed (or other emotions) and 10 being
most depressed (or other emotions), where would you place yourself right now?”
 As to appropriateness, does the client demonstrate emotional responses appropriate
for the situation?
 As to stability, does the client have a normal or labile affect?
 Is the client happy, sad, depressed, anxious, or angry?

2. Facial expressions, gestures, tone of voice

 What facial expressions, gestures, and tone of voice do the client exhibit during the
interview or interaction?
 Does the client demonstrate congruence of facial expressions, gestures, and tone of
voice with affect?

 Is there consistency among the client’s mood, affect, and situation or stimulus?

D. Thought Process and Content

1. Content (what client was thinking) and process (how client was thinking)

Assessment focus questions (data can be determined based on the client’s responses during
the interview):

 Do the client’s verbalizations make sense?

 Do the client’s ideas related and flow logically from one to the next?

#16S Quiling Sur, City of Batac, Ilocos Norte

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 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

 Does the client seem preoccupied (e.g., talking or paying attention to someone or
something else)?
 Do the client’s ideas clear?
 Does the client demonstrate abnormal thought process and content (e.g.,
circumstantial thinking, delusion, a flight of ideas, ideas of reference, loose associations,
tangential thinking, thought blocking, thought broadcasting, thought insertion, thought
withdrawal, word salad)

2. Self-harm or suicide urges

Interview questions:

Ideation: “Are you thinking about killing yourself?”

Plan: “Do you have a plan to kill yourself?”
Method: “How do you plan to kill yourself?”
Access: “How would you carry out this plan? Do you have access to the means to carry out
the plan?”
Where: “Where would you kill yourself?”
When: “When do you plan to kill yourself?”
Timing: “What day or time of day do you plan to kill yourself?”

Ask the client whether the client has thoughts or plans about hurting a family
member, spouse, or anyone else, if the client is angry, hostile, or making remarks about
them. Directly ask the client the following questions:

 What thoughts have you had about hurting (person’s name)?

 What is your plan?
 What do you want to do to (person’s name)?

E. Sensorium and Intellectual Processes

Assessment foci:

1. Orientation

 Does the client recognize person, place, and time?

 Ask the client the following questions: Who are the people around you? Who are you?
Where are you? Where do you live? What is the date today? Today is ______. What
time of the day are we in now?
 Does the client perceive his or her current circumstances? Ask the client the following
questions: “What situation are you in now?” Are you in a troubling situation right now?

#16S Quiling Sur, City of Batac, Ilocos Norte

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 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

2. Confusion

 Is the client unable to make sense of his or her surroundings or figure things out?

3. Memory

Test for immediate and short-term memory: Give the patient three unrelated words
to remember and ask him or her to recite them right after telling them and at 5- and 15-
minute intervals during the interview.

Test for recent memory: Ask about a holiday or world event within the past few
months. (Other events may be asked).

Test for long-term memory: Ask the client about events years ago. (If they are
personal events and the answers seem incorrect, the nurse may check them with a family
member).

4. Ability to concentrate

Ask the client to:

 Spell the word “world” backward.

 Begin with the number 100, subtract 7, subtract 7 again, and so on. This is called “serial
sevens.”
 Repeat the days of the week backward.
 Perform a three-part task, such as “Take a piece of paper in your right hand, fold it in
half, and put it on the floor.” (Give the instructions at one time.)

5. Abstract thinking and intellectual abilities

Ask the client to interpret common proverbs such as the following:

 Proverb: A stitch in time saves nine.

Abstract meaning: If you take the time to fix something now, you will avoid bigger problems
in the future.
Literal translation: Do not forget to sew up holes in your clothes (concrete thinking).

 Proverb: People who live in glass houses should not throw stones.
Abstract meaning: Do not criticize others for things you also may be guilty of doing.
Literal translation: If you throw a stone at a glasshouse, the glass will break (concrete
thinking).

 Does the client have intact abstract thinking abilities?

#16S Quiling Sur, City of Batac, Ilocos Norte

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 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

 Does the client lack abstract thinking abilities, as demonstrated by giving literal
explanation of the proverb/s?
 Does the client have concrete thinking (continually gives literal translations)?

F. Sensory-Perceptual Alterations

1. Hallucinations

 Does the client experience hallucinations (e.g., auditory, visual, olfactory, gustatory,
tactile)?

G. Judgment and Insight

Assessment foci:

1. Interpretation of the environment

2. Decision-making ability
3. Understanding of own part in current situation

 Does the client interpret his or her environment and situation correctly?
 Does the client describe recent behavior and activities that reflect a lack of reasonable
care for self or others?
 Does the client describe risky behaviors reflective of poor judgment?

To assess judgment, ask the client hypothetical questions (e.g., “If you found a stamped
addressed envelope on the ground, what would you do?”). Other questions can be asked.

 Does the client understand the true nature of his or her situation and accept some
responsibility for that situation?
 Does the client have the ability to realistically describe the strengths and weaknesses of
his or her behavior?
 Does the client put blame on others for his own behavior?
 Does the client expects all problems to be solved with little or no personal effort?

H. Self-Concept

Personal view of self

Description of physical self
Personal qualities or attributes

Interview questions:

 How do you describe yourself?

#16S Quiling Sur, City of Batac, Ilocos Norte

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 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

 Please describe yourself in terms of your physical characteristics.

 What personal characteristics do you like?
 What personal characteristics do you want to change?
 What emotions do you frequently experience (e.g., sadness, anger)?
 Are you comfortable with those emotions?
 What do you do when you have a problem? How do you solve it? What usually works to
deal with anger or disappointment?

I. Roles and Relationships

1. Current roles

What roles do you have or assume at present?

2. Satisfaction with roles

How satisfied are you with those roles?

3. Success at roles

How do you perceive your performance in fulfilling those roles?

Do you think you are fulfilling those roles adequately?

4.Significant relationships
5. Support systems

 Do you feel close to your family?

 Do you have or want a relationship with a significant other?
 Are your relationships meeting your needs for companionship or intimacy?
 Can you meet your sexual needs satisfactorily?
 Have you been involved in any abusive relationships?

 When family relationships seem to be a significant source of stress, assess areas of

family functioning practices including:

 Parenting practices, such as methods of discipline, supervision of children, rules

 Patterns of social interaction among family members, expression of feelings
 Patterns of problem-solving and decision-making
 Problems related to housing, finances, transportation, child care
 Relationships with extended family members
 Health behaviors such as mental or physical illness, disabilities, alcohol and drug use

#16S Quiling Sur, City of Batac, Ilocos Norte

 chs@mmsu.edu.ph  077 600 20-56 www.mmsu.edu.ph
 MARIANO MARCOS STATE UNIVERSITY
College of Health Sciences

J. Physiologic and Self-care Considerations

Interview questions:

1. Eating habits

 Please describe your eating pattern and habits.

 Had there been alterations in your eating pattern and habits?

2. Sleep patterns

 Please describe your sleeping pattern.

 Had there been alterations in your sleeping pattern and habits?

3. Health problems

 What major or chronic health problems do you experience?

 What prescribed medications have you been taking?
 What dietary recommendations have you been following?
 Have you been indulged in alcohol?
 What drugs (e.g., over-the-counter, illicit) have you been taking?

4. Compliance with prescribed medications

 What are the factors affecting your compliance with prescribed medications?
 Does your drug produce undesirable effects?
 Has your medication failed to produce the desired results?
 Do you have difficulty obtaining the prescribed medications?
 Is the medication too expensive for you?

5. Ability to perform ADL

Please describe your ability to perform your daily activities, including self-care.

References:

Boyd, M. A. (2018). Psychiatric nursing: Contemporary practice (6th ed.). Wolters Kluwer.

Videbeck, S. L. (2020). Psychiatric mental health nursing (8th ed.). Wolters Kluwer.

#16S Quiling Sur, City of Batac, Ilocos Norte

 chs@mmsu.edu.ph  077 600 20-56 www.mmsu.edu.ph