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NURSING PSYCHOSOCIAL ASSESSMENT TOOL

Clients Name:_Kassie Herp_______________________Date of
Birth:_12/5/1992__________________
Gender: M F

Marital Status:_Divorced__________________

Source of Information (client, relative, other-please specify):

1. Recent stressor(s) (e.g., loss, lifestyle changes, hospitalization, etc.)

Divorce, moving, so I guess lifestyle changes.

2. Current strengths (individual, family, and community) and resources

(spiritual beliefs, culture, or religious affiliation; past problem/crisis
resolution; financial)
I dont have any, Im all alone, Im unhappy, Im no good. I had some good
friends but they arent my friends anymore, everyone always leaves.

3. History of psychiatric treatment or counseling/psychotherapy Have you

sought psychiatric treatment? No_____ Yes__X___ What made you seek
treatment?
My husband said if I dont get help he would leave me.

Explain your response to treatment:

It didnt really help that much. Im just not good enough. But did he ever
think that maybe he is the problem. Why is it always me? I just dont want to
be alone.

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History of family psychiatric treatment or counseling: No__X__
Yes_____ Explain:

4. Support systems (i.e., marital status, job, religious or spiritual affiliations,

and relationships)

5. Suicidal or homicidal potential

Are you having thoughts of killing yourself or others at this time?
No____ Yes_X__ If yes, describe:
Of course I want to kill myself, I have no one.

How long have you had these thoughts?_about a week

now__________ What has stopped you from acting on them?
I havent found the best plan, that is why I have not acted on it.

History of attempt(s): No__X_ Yes_____

Explain:

Dates:___________________
Circumstances:
N/A

Were you abusing drugs or alcohol during the time of the attempt(s)?
No_____ Yes______
N/A
What kind of treatment did you receive?
N/A
Family history of suicide or attempts: No_____ Yes_______
N/A
Relationship:___________________________
Question for family member:

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What is your understanding of the reason(s) for the clients attempt(s)?:
N/A

6. History of substance abuse: No______

Yes__X___
Type: alcohol
Frequency: everyday
Amount: at least a fifth
Last consumption: 10 am this morning
Family history: my dad had a drinking problem
Treatment history: no treatment
Length of sobriety: couple hours if you could call it that
Legal history: none, but I wouldnt if it happens soon.
Blackouts: No____ Yes__X___
Explain:
I usually keep drinking until I pass out.

Withdrawal seizures: No__X___ Yes_____

Explain:
N/A

Hallucinosis or delusions: No__X__ Yes______

Explain:
N/A
History of severe withdrawal requiring immediate medical attention or
hospitalization:
No_X___ Yes_____
Consequences of substance misuse: No____
Yes__X___ Explain:

Health/Medical_____
Psychiatric_____
Legal_____
Occupational_____

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Interpersonal_Divorce everyone hates me____

7. Mental status examination

Level of consciousness: Alert __X__ Drowsy _____ Other (describe):
Cooperative: No_____ Yes__X__
Mode of arrival: Neighbor brought, she just wanted to get rid of me. She
thinks Im crazy, she doesnt care. Why does everyone hate me so much?
Accompanied by: No one
Describe:

General appearance:
Disheveled, not put together, bruises on her arms and hands.

Orientation: Person_____ Place_____ Date/Time______

Dress: Appropriate _____ Neat_____ Disheveled_____ Other___________
Eye Contact (consider cultural aspects): Good_____ Poor_____
Affect: Congruent/appropriate______ Flat_____ Blunted______
Hallucinations: No_____ Yes__X__ Auditory __X__ Visual_____
Other______ Describe any of the above as needed:
Sometimes I hear people tell me Im not good enough, would
everyone just leave me alone, I know I am no good. Why do you
think Im planning to kill myself.

Delusions: No_X___ Yes _____ Persecutory _____Grandiose

_____ Describe:

Illusions: No__X__ Yes_____

Describe:

Obsessions: No_X___ Yes_____

Describe (Do you have habits that bother you?):
Compulsions: No_X___ Yes_____
Describe (Do you have special ways that you do things?):

Phobias: No_____ Yes__X__

Describe:
I dont want to be alone
anymore. Im always alone.

Speech: Clear_____ Rapid_____ Slurred_____ Pressured_____ Aphasic_____

Mute_____ Mood: Appropriate_____ Anxious _____ Agitated _____ Elated_____
Depressed_____ Other___
Activity Level: Appropriate_____ Restless_____ Psychomotor retarded_____
Lethargic_____

Agitation_____ Tremulous_____ Changes position

often_____ Explain:

Ability to abstract:
Memory: Intact_____; Difficulty with: Recent events_____ Remote events______

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Test recent memory with 3 objects in a 5 minute exercise (when needed)
Thought processes: Logical _____ Relevant_____ Coherent_____
Does patient look stated age? Yes_____ No______; Older_____ Younger_____

8. Medical history
During the past 6-12 months, have you had changes in the following:
Sleeping patterns? No_____ Yes__X___
Describe:
I like to sleep a lot, but sometimes I
cant sleep because all I can think about
is reasons why I should die.
Appetite? No_____ Yes__X__
Describe:
I dont eat much whats the point.
Weight? No_____ Yes___X__
Describe:
But it doesnt matter because Im always going to be ugly.
Concentration patterns? No_____ Yes__X__
Describe:
All I can think about is dying
Energy Level? No_____ Yes__X__
Describe:
The only energy that I have is enough energy to figure out how I am going to
kill myself.
Libido? No__X__ Yes_____
Describe:

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I dont have anyone to have sex with so it doesnt matter, if you must know!
Mood? No_____ Yes_X___
Describe:
Im sad, mad, angry, dont care.
Current medical treatment: No__X__ Yes_____
Explain:
None but maybe I should get some to help speed up the process.
Current medication(s): No__X__ Yes_____ List any below with dose/times
None but maybe I should get some to help speed up the process.

How long have you taken each of these medications?

Directions for taking:
N/A
What is your understanding of the reason(s) for taking this medication?
N/A
Are you taking your medications as ordered by your physician or provider?
No_X___ Yes_____ Explain: Do not currently have any meds.

List all over-the-counter medication

N/A

List all herbal medications (e.g., St. Johns Wort, Kava Kava) or
complementary therapies (i.e.
acupuncture)
N/A
Surgical procedures during the past 12 months: No__X__
Yes_____ Explain:

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N/A

Allergies: No_X___ Yes_____

Describe reaction:

9. Family/Social/Work History:
Describe your living situation (number of people in the household, own
home/rent/ other)
I live by myself and I rent. Nobody wants to be around me, everyone always
leaves.
Do you feel safe in your current living situation? Explain:
Does it matter, Im going to die anyway.

Have you ever been a victim of abuse from a family member? Explain:
Not really. I just get yelled at a lot as a kid, I could never do anything right,
ever.
Have you ever been a victim of abuse from other? Explain:
N/A

Description of work history to present:

I dont have a job right now. I got fired. I showed up late a lot and I
apparently was mean to the customers. I have never really been able to
keep a job for a year. I always have trouble. I guess its just because I am
crazy and everyone hates me so they just get rid of me. I try to be good, but
its just not good enough.
Describe ways you have coped with stressors in the past? Did you find these
to be effective?
I just drink right now. It helps a little bit, but not a lot. I just usually cry a lot
and get really angry. Sometimes I feel like screaming works. But it doesnt
last for long, because I am a failure and everyone just wants to leave me so it
just makes everything worse.
Any spiritual concerns?

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None

Evaluation of reading ability? Any special needs that we need to be aware of?

10.Anything else you want to share?

Not really other than I am going to die soon. Are you done yet, Im pretty sick of
getting questioned a million times. But please dont leave!

OVERALL IMPRESSIONS: