PSYCHOSOCIAL NURSING ASSESSMENT

1. Lifestyle Information

L.D.D. is a 57 years old, female, currently living at Brgy. Paloc Sool, Dumangas, Iloilo with her children.
She usually wakes up at around 5-6:00 am in the morning to make breakfast for her children. She is a
housewife and usually cleans the house. She doesnt smoke nor drink alcoholic beverages. She is in good
ties with her neighbors.

2. Normal Coping Patterns

Whenever L.D.D experience problems she usually talks to her children to seek for advice. She also shares
her problems to her sister as a way of expressing her feelings

3. Understanding of Present Illness

Patient is unresponsive

4. Personality Style

Patient was unresponsive.

5. History of Psychiatric Disorder

She never experienced any severe depression, severe nervousness, nor has she taken any antidepressant or
psychoactive drugs.

6. Recent Life Changes or Stressors

She considers her current hospitalization as her current life changing situation mainly because of financial
matters and she cant anymore perform her ADLs.

7. Major Issues Raised by Current Illness

Indi na kami kapangita ubra kay ari kami gabantay kay nanay. As verbalized by the folks

8. Mental Status Examination

APPEARANCE

Neat Clean Dishevelled Poor Grooming Erect Posture

Good eye contact Inappropriate makeup others: _______________

Description: L.D.D appeared neat and clean. She is well-groomed.

 BEHAVIOR

Calm Appropriate Restless Agitated Compulsions

Unusual actions others: _______________

Description: Patient was unresponsive.

SPEECH

Appropriate Pressured Loose Association Loud Soft

Mute others: _______________

Description: Patient was unresponsive.

MOOD/AFFECT

Appropriate Labile Flat Depressed Worried Anxious

Angry Hopeless others: _______________

Description: Patient was unresponsive.

THOUGHTS

Appropriate Low Self-Esteem Suicidal Ideations Hallucinations

Delusions Phobias others: _______________

Description: Patient was unresponsive.

ABILITY TO ABSTRACT

Impaired: YES NO

Description: Patient was unresponsive.

MEMORY

Impaired recent memory: YES NO

Impaired past memory: YES NO

Number of objects able to remember after 5 minutes:

Description: Patient was unresponsive.

ESTIMATED INTELLIGENCE

Below Average Average Above Average

Description: Patient was unresponsive.

CONCENTRATION

Able to focus Easily distractible

Able to subtract backwards by 7s from 100 correctly until number ___.

ORIENTATION

Person Time Place Situation

JUDGMENT

Realistic decision making: YES NO

Description: Patient was unresponsive.

INSIGHT

Good Fair Poor

Description: Patient was unresponsive.