Psychosocial Assessment: A Nursing Perspective

A psychosocial assessment evaluates an individual's mental health and social well-being. It assesses self-perception and the individual's ability to function in the community. The goal of a psychosocial assessment is to understand the patient to provide the best care possible and help the individual obtain optimal health.

A psychosocial assessment aims to gather comprehensive information about an individual's psychological and social functioning to understand their current situation, identify their strengths and challenges, and develop an appropriate plan for intervention or treatment. The primary objectives of a psychosocial assessment include understanding the individual's background, assessing psychological functioning, evaluating social functioning, identifying strengths and resources, and determining needs and challenges.  

The first step includes understanding the individual's background. This step involves gathering information about the person's history, including family background, education, employment, and social relationships. It explores significant life events, traumas, or transitions that may impact their current situation.

Next, psychosocial functioning is assessed. This step includes evaluating the individual's mental health status, including symptoms of any psychological disorders such as depression, anxiety, or post-traumatic stress disorder (PTSD) to help determine cognitive functioning, emotional well-being, and behavior patterns. Then, social function is evaluated by understanding the individual's social interactions, support systems, and community involvement, and assessing the quality of relationships with family, friends, and colleagues.

Next, strengths and resources are identified, including personal strengths, coping mechanisms, and resilience factors. The clinician should seek to recognize available resources such as support from family, friends, community services, and financial resources. Then, needs and challenges are determined, which includes identifying any barriers to optimal functioning, such as substance abuse, financial difficulties, housing instability, or lack of social support. Highlight areas that need intervention, such as mental health treatment, vocational training, or social support services.

Then, a tailored intervention or treatment plan is created based on the gathered information. The plan sets realistic and achievable goals for improving the individual's psychological and social functioning. Coordinate with other professionals and services to provide comprehensive care. 

Lastly, progress is monitored and evaluated. Establish a baseline for future assessments to monitor the individual's progress. Adjust the intervention plan as needed based on changes in the individual's situation and response to treatment. The psychosocial assessment aims to understand the individual holistically to facilitate effective and personalized support and intervention.  See Table 1 below for more information.

The first step in any assessment is to identify the patient. A patient's identity includes name, gender, birth date or age, marital status, race, ethnicity, and language.

The chief complaint is the main reason the patient presents, in their own words. The history of the present illness is a chronological account of what led up to the chief complaint. This section may include the problem's location, duration, severity, timing, context, modifying factors, and associated signs or symptoms.

The psychiatric psychological history is the history of all psychiatric or psychological concerns in the past. The medical or surgical history includes listing all medical illnesses, surgeries, and dates. All current and past medications should be listed, including the dose and frequency. A listing of who prescribed them and why they are prescribed should be documented for medications currently taken. A listing of why they were started and stopped should be documented for past prescribed medications.

History of alcohol and drug use is important in the psychosocial assessment. The substances currently used should be documented, including the method of use (oral, inhalation, injection, intranasal), the amount, the frequency, and the time. Any substances used in the past should be documented. Commonly abused substances include alcohol, heroin, opiates, marijuana, cocaine, crack, methamphetamines, inhalants, stimulants, hallucinogens, caffeine, and nicotine.

Violence risk includes an assessment of suicidal ideation, homicidal risk, and abuse. While it is difficult to predict who will commit suicide, risk factors for suicide include a previous suicide attempt, family history, feelings of hopelessness, drug and alcohol abuse, history of depression or bipolar disorder, feeling isolated, physical illness, history of aggressiveness or impulsivity, and unwillingness to seek help or barriers to mental health treatment (Centers for Disease Control and Prevention [CDC], 2024).

Risk factors for homicidal behavior include male gender, gang affiliations, unemployment status, drug or alcohol use, active psychotic symptoms, availability of weapons, cultural norms, and lower socioeconomic status (World Health Organization [WHO], 2019).

Questions to ask in assessing suicidal or homicidal ideation and abuse are included in Table 2.

The social history provides clues as to how the person interacts with others. It is important to understand social relationships as those with a large social network are more likely to have less severe mental illness and recover better from mental and medical illness. The nurse should have the patient describe their social relationships, including siblings, spouse/partner/significant other, children, current living situation, military history, discharge type, and any additional support or social networks reported. Any significant life event, such as death, divorce, or birth, should be reported.

Family history is important because many mental illnesses are hereditary. Record any history of mental illnesses in the patient's family. Common genetic illnesses include depression, bipolar disease, schizophrenia, and attention deficit disorder.

Employment history is important. Record the patient's current employment status and occupation. If the patient is currently employed, determine if this is a long-term job prospect or a temporary job. Determine how they function at their job. Do they perform their job well? Do they get along with co-workers? Has the patient ever been fired? How many jobs has the patient held in the last five years? Patients who have held multiple jobs in the recent past are more likely to have an avoidant personality disorder.

Determining educational history will help the nurse understand how to interact with the patient best. What is the highest grade that the patient completed? Where did the patient go to school? Were there any discipline problems at school? Assessing how the patient functions at work and school can provide helpful clues to the patient's mental health status.

A quick screening of the patient's legal history is important. Determine if the patient has legal trouble, probation, parole, pending charges, or incarceration. There is a strong link between legal problems and mental illness.

Developmental history will provide insight into the origins of behavior and help diagnose and manage some conditions. Any psychological trauma experienced as a child may lead to problems in adulthood. Determine how the patient functioned in their childhood concerning school, friends, personality, and hobbies. Also, determining the patient's sexual orientation will help the nurse better plan care for the patient.

The spiritual assessment should note the patient's religious background. The clinician should assess the degree of involvement within the religious community and any spiritual practices. Nurses who understand the patient's spiritual views will be better able to be empathetic. It can also help the nurse determine if the patient has unresolved spiritual needs or concerns. Unresolved spiritual issues will inhibit recovery. When spiritual concerns are identified, appropriate referrals may help ensure holistic wellness.

The cultural assessment should list critical issues regarding the patient's ethnic and cultural background. A nurse cannot fully understand every culture, but a good cultural assessment will help the nurse understand the patient's beliefs, values, and practices. These factors can be respected and considered when providing care. Different cultures express, report, and develop mental illnesses in different ways.

The financial assessment should describe the patient's financial situation. Understanding the patient's financial situation is important for multiple reasons. Patients in a lower socioeconomic class are at higher risk for many health conditions. Also, patients with limited financial resources may need help with money and may benefit from a social worker's consultation.

Determining coping skills is an important part of the psychosocial assessment. If the nurse understands the patient's current coping techniques, they will provide better care by fostering adaptive coping skills. Determining the patient's abilities and interests helps get a full picture of the patient. Ask the patient: What are their hobbies? What are they good at doing? What gives the patient pleasure?

The mental status examination assesses the function of the brain, mental functions, and behaviors. A good mental status examination helps assess many mental health or central nervous system disease states. A good mental status examination can be used over time to monitor a patient's severity of illness (Voss & Das, 2024).

The first step in the mental status examination determines the patient's degree of arousal. Is the patient alert, sleepy, attentive, or unresponsive? Is the patient oriented to person, place, and time, or is the patient confused?

How does the patient look? Is the patient well groomed? Is eye contact appropriate? Note poor hygiene, inappropriate dress, and lack of concern for appearance. Poor grooming indicates a potential psychiatric problem. Stooped posture and poor eye contact suggest depression. Colorful clothes or unusual clothing suggest a manic state.

Assess behavior and motor activity. Is the patient calm and relaxed, or is there any indication of restlessness, agitation, or lethargy? Note abnormal motor movements such as unusual facial expressions, tremors, or tics. Tremors or tics suggest a neurological disease, medication side effect, or anxiety. Excessive body movements suggest mania, anxiety, or stimulant use. Repeated motor movements suggest obsessive-compulsive disorder or a neurological disorder. Minimal body movement may be depression, catatonic schizophrenia, or drug abuse.

Evaluate the mood and affect. Asking patients how they feel is a simple way to assess their mood. Is the patient's emotional response to the situation appropriate? Observe the verbal or non-verbal behaviors to determine mood. Mood disturbances may be demonstrated by inappropriate feelings or behavior toward the situation. Note euphoria, agitation, depressed mood, flat affect, anxiety, emotional lability (shifting from one affect to another rapidly), irritability, excessive rage, indifference, carelessness, inability to sense emotions, and lack of sympathy.

Many tests are available to assess cognition. The MMSE is a well-known test that assesses multiple domains, can be done in 5 to 10 minutes, and is rated on a scale from 0 to 30. The MMSE is useful for screening for cognitive impairment and monitoring cognitive changes over time. It is not recommended as a diagnostic tool. The MMSE score is affected by culture, age, education, and gender (Matthews et al., 2012).

The Clock Drawing Test (CDT) is another screening tool for cognitive problems, especially dementia. The CDT is widely used to screen for dementia due to its simplicity and effectiveness. Studies have reported varying levels of sensitivity and specificity for the CDT. In a study focusing on post-stroke neurocognitive disorder, the CDT showed a sensitivity of 68% and a specificity of 61% for any neurocognitive disorder, using a cutoff score of <5. For major neurocognitive disorders, the sensitivity was 78%, and the specificity was 53%​ (Navickaite et al., 2024).

In the CDT, the patient is given a piece of paper with a pre-drawn circle. The patient is to draw numbers in the circle to make the circle look like a clock's face. The patient is given a time. Ten after 11 is often used, drawing the clock's hands to read that time. A cognitively intact patient should make no errors or only minor visual-spatial errors, such as slightly drawing outside the circle or mild spacing problems.

Beck's Depression Inventory asks 21 questions and rates them on a scale from 0 (minimal) to 3 (severe). It is recognized as a reliable and valid instrument for measuring depression (Lee et al., 2017). The questions focus on sadness, hopelessness, guilt, self-dislike, loss of energy, insomnia, fatigue, anhedonia, irritability, crying, lack of interest in sex, agitation, self-blame, past failure, punishment, suicidal thoughts, loss of interest in activities, indecisiveness, worthlessness, decreased appetite, and diminished concentration. The score is tallied, and scores over 30 are classified as severe depression. Less than 15 is mild to no depression, and 15-30 is moderate depression.

Two commonly used scales are available for older adults. The geriatric depression scale is useful to assess depression in older adults with an MMSE score above 10 (Conradsson et al., 2013). The Cornell Depression Scale is useful to screen for depression in those with dementia. It asks 19 questions across five categories (Maurer et al., 2018). It evaluates mood (sadness, affect, anxiety, irritability), behaviors (agitation, movement, slow speech), physical signs (weight loss, low energy), cyclic function (insomnia, mood fluctuations), and ideation disturbances (suicide, pessimism).

There may be many reasons to refer a patient to a mental health professional. Also, there are many mental health professionals to refer to, depending on the situation. Different mental health professionals and who should be referred to them are included in Table 7. Many indicators become evident when a complete assessment is finished.

Some general guidelines for referral to a primary healthcare provider or psychiatrist include:

• The patient is showing depressive symptoms (review SIG-E-CAPS), especially a decline in the ability to experience pleasure or prolonged sadness
• Any suicidal or homicidal gestures (immediate referral)
• Any dangerous behaviors such as self-harming behavior (e.g., cutting)
• Excessive anxiety (e.g., panic attacks, irrational fears, phobias)
• Intrusive thoughts
• Periods of euphoria are associated with a reduced need for sleep or impulsive or risk-taking behavior (e.g., an increase in promiscuous sex, excessive drug or alcohol use, or spending sprees)
• Severe irritability or outbursts of anger (e.g., argumentative, easily annoyed, easily upset)
• Psychosis (e.g., hallucinations, delusions, paranoia)
• Addictive behaviors (e.g., drug use, excessive alcohol use, excessive overeating)
• Signs and symptoms of abuse (physical, emotional, or sexual)

Patients who may benefit from psychotherapy include those with:

• Non-compliance with medical treatment
• Unresolved grief
• Parenting or family issues
• Struggles with adjustment to major life changes (e.g., death, move, divorce)
• Self-sabotaging behavior (e.g., drug or alcohol abuse, binge eating)
• Anger issues or impulse control
• Significant relationship problems (e.g., dependency, manipulation, infidelity)

Presenting Problem: Steve F. is an 82-year-old widowed white male. He presents to his primary healthcare provider because his family is concerned about his memory loss. He has been becoming more forgetful and is having problems functioning independently. Specifically, he gets lost when driving and has problems preparing his meals.

Past History: Steve has been an extremely healthy individual. He is not afflicted with a history of any medical, surgical, or psychiatric problems. He currently takes no medications and has never been on chronic prescription medications.

Drug or Alcohol History: Steve has been a lifelong nonsmoker, has never used illegal drugs, and reports drinking a glass of red wine 3-4 times a week for most of his adult life.

Suicidal or Homicidal Ideation: He denies any suicidal or homicidal ideation. There is no history of abuse in his past.

Family and Social History: Steve was married for 51 years and has been a widow for six years. He currently lives alone in his home and has no close-living friends. He has one grown daughter and two grandchildren living over 100 miles away.

Employment history: He worked 44 years at a steel factory and has been retired for 18 years.

Education: Steve dropped out of high school in the 11th grade and reports he was an average student.

Crime or Legal Trouble: He has never had any legal trouble.

Developmental History: No significant abnormalities were reported.

Spiritual Assessment: He reports being a Catholic and regularly attending mass.

Cultural Assessment: He considers himself an American.

Financial Assessment: He reports no financial issues.

Coping Skills: He reports limited stress and copes with stress well.

Interests and Abilities: He reports that his favorite activities are spending time with family and reading.

Mental Status Exam: Steve is an alert, calm-appearing white male who appears to be his stated age and is accompanied by his daughter. He has dressed appropriately and is well-groomed. He was cooperative and polite during the interview and maintained good eye contact. His mood is normal, and his affect is appropriate. His rate of speech is slow, and his speech is soft. His thought process showed a limited ability to think abstractly and some loose associations. His thought content was normal and did not demonstrate paranoia, aggressiveness, or obsessive thinking. No psychotic thinking was demonstrated. He was oriented to person and place but could not report the day of the week. He had normal impulse control and demonstrated normal judgment during the exam.

The patient's functional ability was of slight concern. He can generally care for himself independently, but there has been a 5-pound weight loss over the last three months without a known cause. There have been multiple problems with bills being paid late, and the patient has received many calls from creditors. He has had some problems preparing meals for himself. Of greatest concern to the daughter was that the patient got lost coming home from the mall last week, which he has been going to for over 20 years.

His cognition or knowledge was tested with the MMSE, in which the patient scored 24.

Based on the psychosocial assessment, it is determined that the patient has some dementing illness. The medical doctor diagnosed Alzheimer's disease. Given self-care problems, the patient will be moved to an assisted living facility with part-time nursing care. The assisted living facility will monitor the patient closely to meet all self-care needs. Moving to a long-term care nursing facility will be considered if self-care needs are unmet.

This comprehensive psychosocial history helped the primary care physician diagnose and fully understand the patient's impairments. Based on the strength of the psychosocial history taken by the nurse, the patient will now receive safe and effective care. If a complete psychosocial assessment was not taken, it might have been determined that the patient functioned well in his house. Allowing the patient to return to his home may have led to a poor quality of life for him and his family.

The psychosocial assessment starts with a general psychosocial history and concludes with a mental status examination. The psychosocial assessment allows the nurse to pick up on many psychological or social issues that, if addressed, can significantly improve the patient's quality of life with proper intervention. To provide optimal patient care, the nurse must know how to perform a good psychosocial assessment and when to refer to another healthcare provider.

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