School of Nursing

NCM 117 –RLE - PSYCHIATRIC NURSING

PSYCHOSOCIAL ASSESSMENT

1. Profile

Elmer Corbua Barredo 54

Name_____________________________________________________________Age_____________________________
Gender______________________Nationality__________________________Status
Male Filipino ______________________________
Roxas City, Capiz
Address____________________________________________________________________________________________
Dateof Birth______________________________________________Date
September 6, 1969 of Admission____________________________
May 5, 1994
Educational Attainment_____________________________________Occupation_________________________________
Unknown
Roman Catholic Undifferentiated Schizophrenia
Religion________________________________Diagnosis_____________________________________________________

2. Chief Complaint (the main reson why the client went to the hospital for consultation)

3. History of Present Illness (recent illness and hospitalization for consultation)

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 4. Past Medical History (Past illnesses and hospitalization, management)

5. Past Psychiatric History (age of onset, the course of illness, specific symptoms, hospitalization, treatment and
effect of treatment)

6. Familial History (Family medical/psychiatric history)

7. Personal History
• Prenatal/Perinatal
• Early childhood
• Middle childhood
• Late adulthood (Puberty through adolescent)
• Adulthood
Occupational history
Marital and relationship history
Educational history
Religion history

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 Social activity
Living condition
Legal history

COMPONENTS ASSESSMENT ANALYSIS & INTERPRETATION

According to Mayoclinic, abnormal
Elmer is a 54 years old Filipino male. At the time motor behavior for schizophrenia may
of the interview, he was well groomed and dressed. show in a number of ways, from childlike
but has decayed and missing teeth. There were silliness to unpredictable agitation.
signs of unusual behavior such exhibiting a silly- Behavior isn't focused on a goal, so it's
GENERAL ASSESSMENT & child like behavior (self-absorbed smiling and hard to do tasks. Behavior can include
MOTOR BEHAVIOR laughing. The client engaging repeatedly resistance to instructions, inappropriate or
movements of flexion of the knee while bizarre posture, a complete lack of
interviewing. The client speech is altered since he response, or useless and excessive
didn't respond to the question and maintain quiet. movement.
The client displaying inappropriate affect, often According to Videbeck, The client’s mood
laughing while interviewed. He is appeared anxious may be described as happy, sad, depressed,
and irritable while questioning if he has a family euphoric, anxious, or angry. When the
and educational attainment. client exhibits unpredictable and rapid
MOOD & AFFECT mood swings from depressed and crying to
euphoria with no apparent stimuli, the
mood is called labile (rapidly changing).

Elmer exhibiting formal though disorders, He wasn't
able to answered questions simultaneously and
directly. Elmer did experience though block when
THOUGHT PROCESS & exploring family history. The client also
CONTENT experiencing delusion of his actual age, he said that
he is only 22 years old .
According to Videbeck, Thought blocking
is abnormal assessment , it is stopping
abruptly in the middle of a sentence or
train of thought; sometimes unable to
continue the idea . Alterations in thought
are false fixed beliefs that cannot
be corrected by reasoning and are usually
bizarre. T

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 The client is oriented in the time, place, and name The orientation is usually intact the
however, he didn't recall his family and educational patients know who and where they are
SENSORIUM & attainment and other past history aside his name. and what time it is.
INTELLECTUAL The client also has inability to concentrate, he
PROCESSES didn't respond to the questions being asked and
refuse to the perform certain tasks.
As the client interviewed, He said randomly
"may aswang dito" and didn't respond to the
ABNORMAL SENSORY following questions about what he said.
EXPERIENCES OR
MISPERCEPTIONS
The patient has a lack of insight and judgement
since he didn't respond to the questions and stay
quietly.
JUDGMENT & INSIGHT
The client asked about his self and what he want
to talk about, the client responded "kawawa na
ako dito" and asked "paano niyo po nasabing
kawawa na kayo dito" and didn't
SELF-CONCEPT respond to the question instead laughed.
The client don't know his family as being
interviewed.
ROLES & RELATIONSHIP
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According to Videbeck, Visual
hallucinations is seeing things that don’t
really exist. It Involve seeing images that
do not exist at all, such as lights or a dead
person, or distortions such as seeing a
frightening monster instead of the nurse.
Judgment refers to the ability to interpret
one’s environment and situation correctly
and to adapt one’s behavior and decisions
accordingly. Insight is the ability to
understand the true nature of one’s situation
and accept some personal responsibility for
that situation.
According to Videbeck, Self-concept is
the way one views oneself in terms of
personal worth and dignity. The client
has a poor self concept
The ability to fulfill a role or the lack of a
desired role is often central to the client’s
psychosocial functioning. Changes in
roles may also be part of the client’s
difficulty.
 PHYSIOLOGIC & SELF CARE As being observed, the client eat Emotional problems can greatly affect
CONSIDERATION properly. eating and sleeping patterns; under stress,
people may eat excessively or not at all
and may sleep up to 20 hours a day or be
unable to sleep more than 2 or 3 hours a
night.

DATA ANAYLYSIS

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